HX00033596 


THE    TONSILS 


AND 


THE    VOICE 


RICHARD  B.  FAULKNER,  M.D. 


^^tintmt  Ktbrarg 


Digitized  by  tine  Internet  Archive 

in  2010  witin  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/tonsilsvoiceinscOOfaul 


The  Tonsils  and  The  Voice 


IN 


Science,  Surgery,  Speech  and  Song 

A   COMPREHENSIVE    MONOGRAPH 

ON  THE 

Structure,  Utility,  Derangements  and  Treatment 

of  the  Tonsils,  and  of  their  Relationship 

to  Perfect  Tone  Production 

A    RESEARCH    STUDY 

With  Original  Contributions  from  the 
Highest  Medical  and  Voice  Authorities 


BY 

RICHARD   B.  FAULKNER,  M.D. 

(COLUMBIA  UNIVERSITY) 


WITH  AN  INTRODUCTION 
BY 

PROFESSOR   GEORGE  M.    SLEETH 
Instructor  in  Elocution,  Western  Theological  Seminary 


THE  PRESBYTERIAN   BOOK  STORE 
PHTSBURGII.  I'A. 


COPYRIGHT,  1913, 

BY 

RICHARD    B.    FAULKNER,  M.D. 


THE  BLANCHARD  PRESS 
NEW  YORK 


PREFACE 


Tonsils!  What  are  they?  What  are  their 
functions  ?     Who  knows  ?     What  textbook  tells  ? 

I  have  made  a  research  investigation,  and  this 
book  gives  the  result.  Lights  and  side-lights  fell 
upon  my  path.  Delicate,  difficult,  complex, 
technical  questions  of  the  voice  arose.  Two  pro- 
fessions became  involved. 

No  treatise  on  the  tonsils  is  complete  unless  it 
includes  the  questions  of  the  voice,  for  the  tonsils 
and  the  voice  are  inseparable  subjects. 

This  is  the  only  work  in  which  a  systematic 
effort  has  been  made  to  connect  the  viewpoints  of 
both  the  medical  and  voice  professions,  in  an  or- 
derly and  authoritative  manner. 

This  is  the  only  work  on  the  subject  published 
in  any  language.  This  is  the  only  work  in  which, 
in  addition  to  its  physiological  functions,  the  ton- 
sil is  treated  as  a  mechanical  body,  and  the  action 
of  its  mechanism  fully  expounded. 

This  work  contains  all  the  facts  of  a  world's  re- 
search on  the  structure,  uses,  disorders  and  treat- 
ment of  the  tonsils ;  many  new  facts  in  the  science 
of  the  vocal  art ;  and  in  addition,  a  full  exposition 
of  the  modern  hygiene  of  the  tonsil,  the  hygiene 
of  the  voice,  and  the  care  and  health  of  the  nose, 
mouth  and  throat. 

That  "the  voices  of  singers  and  public  speakers 
are  benefited  by  complete  removal  of  the  ton- 
sils"; that  "the  loss  of  the  tonsils  may  cause  a 


IV 


PREFACE 


permanent  loss  of  the  singing  voice  is  a  puerile 
and  senseless  belief" ;  that  "If  the  tonsil  in  a  ?zor- 
mal  state  is  removed  in  toto,  there  is  no  disastrous 
after  effect,  but  on  the  contrary,  the  individual  is 
improved  in  health,  and  the  richness  in  qualit}^  of 
voice  and  the  volume  of  tone  are  increased  one 
hundred  per  centLmi" ;  are  common  statements  in 
the  standard  works  of  the  American  medical  pro- 
fession. These  statements  are  important.  Are 
they  the  truth?  What  is  the  answer  of  the  voice 
profession  ? 

I  am  gratified  at  the  courteous  contributions, 
and  also  with  the  expressions  of  regard  for  the 
importance  of  the  work  I  have  undertaken,  which 
I  have  received  from  such  distinguished  medical 
and  voice  authorities  as  Von  Chiari  (Vienna), 
Frankel  (Berlin),  Von  Schrotter  (Vienna), 
Brieger  (Breslau),  Von  Levinstein  (Berlin), 
Mar  age  (Paris),  Jacohi  (Xew  York),  Es- 
cat  (Toulouse),  Moure  (Bordeaux),  Castex 
(Paris),  JLeimoyez  (Paris),  Sir  Felix  Senion 
(London),  Beverley  Robinson  (Xew  York), 
Von  Giitzmann  (Berlin),  Gleitsniann  (Xew 
York),  Schmiegelow  (Copenhagen),  Van  Bag- 
gen  {The  Hague),  Liihet-Barbon  (Paris),  Z/WC 
(Paris),  Natter  (Paris),  Helsnioortel  (Ant- 
werp), Loezvenherg  (Berlin),  St.  Clair  Thom- 
son (London),  H.  Holbrook  Curtis  (Xew 
York),  Scripture  (Xew  York),  Miller  (Xew 
York),  Baonlt  (Xancy),  Zund-Burguet 
(Paris) ,  Massei  (Xaples) ,  Knight  (Xew  York) , 
Barth  (Leipzig),  Holmes  (Boston),  Mackenzie 
(Baltimore),  Gleason  (Philadelphia),  Cassel- 
berry    ( Chicago ) ,   Eo.^s    ( ^lontreal ) ,  ■  JLaniperti 


PREFACE  V 

(Berlin),  Mme.  Cappiani  (New  York),  Mme. 
Mott  (New  York),  De  Reszke  (Paris),  Mme. 
Lehmann  (Berlin),  Sehastiani  (Naples), 
Shakespeare  (London),  Sii'  Charles  Santley 
(London),  Sabatini  (Milan),  Mme,  Patti  (Bre- 
conshire,  Wales),  Mine.  Nordica  (New  York), 
Mme.  Schumann-Heink  (New  York),  Mme. 
Tetrazzini  (New  York),  Mme.  Clara  Kathleen 
Rogers  (Boston),  Bond  (New  York),  Bispham 
(New  York) ,  Curry  (Boston) ,  and  others. 

The  object  of  this  work  is  to  present  known 
facts,  the  latest  views  of  the  most  eminent  authori- 
ties, and  the  indications  which  denote  safe  lines  of 
treatment  as  against  the  apparent  indiscriminate 
and  reckless  disregard  of  tonsillar  function. 

The  author  will  feel  rewarded  if  his  efforts 
please  the  expert  laryngologists,  and  other  inter- 
ested members  of  his  own  profession,  as  well  as 
the  voice  mechanicians,  voice  trainers  and  voice 
users. 

My  thanks  are  due  to  Dr.  Kniffler  (now  of 
Wiesbaden),  Mr.  Charles  H.  Read,  and  Profes- 
sor George  M.  Sleeth,  for  their  valuable  assist- 
ance in  the  preparation  of  this  work. 

Richard  B.  Faulkner.. 

100  Fifth  Avenue, 
Pittsburgh,  1913. 


INTRODUCTION 


Dr.  Richard  Biddle  Faulkner  needs  no  intro- 
duction. He  received  the  degree  of  Doctor  in 
Medicine  from  the  College  of  Phj^sicians  and  Sur- 
geons in  the  City  of  New  York,  Columbia  Uni- 
versity, and  also  received  special  instruction 
under  Professors  Alonzo  Clark,  Charles  McBur- 
ney  and  John  G.  Curtis. 

Many  scientific  contributions  from  his  pen  have 
appeared  in  the  leading  medical  journals  of 
America. 

The  starting  point  of  the  present  treatise,  the 
author  says,  was  a  question  asked  him  by  the 
writer  of  this  introduction.  Being  a  teacher  of 
the  voice  and  delivery  for  over  thirty  years  in  the 
same  city  with  Dr.  Faulkner,  and  having  had  oc- 
casion for  many  years  to  avail  myself  oip  his  skill 
in  laryngology,  both  for  myself  and  my  students, 
I  one  day  asked  the  doctor,  "What  are  the  tonsils 
for?"  This  book  is  the  answer.  Behold  how 
great  a  matter  is  kindled  by  how  very  small  a 
fire!  He  started  upon  a  new  and  thorough  in- 
vestigation. He  has  ransacked  Europe  and 
America  to  give  us  the  answer.  And  he  presents 
the  testimony  of  those  best  qualified  to  speak  on 
the  matter. 

The  book  contains  contributions  from  world- 
renowned  artists  and  teachers  and  scientific  inves- 
tigators. 

Not  the  least  interesting  and  profitable  part  of 


viii  INTRODUCTION 

the  work  is  that  which  gives  the  most  recent  and 
authoritative  treatment  of  the  tonsils,  and  the 
great  discoveries  which  have  been  made  in  the 
science  of  the  voice,  as  regards  its  mechanism,  its 
preservation,  its  use  and  its  treatment. 

As  a  result  of  the  investigations,  teachers  of 
the  voice,  both  in  speech  and  song,  will  be  more 
careful  in  recommending  tonsil  surgery  as  a 
panacea  for  voice  users.  The  treatment  of  the 
vocal  apparatus  is  a  specialty.  The  ideal  expert 
would  be  one  who  combined  laryngological  skill 
and  a  sound  knowledge  of  the  theory  and  practice 
of  the  voice. 

Literature  on  the  subject  of  the  connection  be- 
tween the  tonsils  and  the  voice  is  scanty.  And 
when  reference  is  made  to  the  subject,  it  is  gener- 
ally some  wild  surmise,  or  bare,  unsupported 
dogmatism,  or  sheer  tradition. 

There  is  an  originality  of  investigation  and  a 
freshness  in  the  method  of  treatment  of  the  sub- 
ject, which  renders  this  work  unique.  Specialists 
will  be  grateful  to  have  so  much  information  and 
such  a  gathering  of  famous  opinion,  in  so  com- 
pact and  orderly  a  form. 

George  M.  Sleeth. 


CONTENTS 


PAGE 

Preface  iii 

Introduction  by  Professor  SleEth  vii 

Chapter          I.    Research    Investigation 1 

Chapter        M.  Anatomy  of  the  Tonsil 7 

Normal  Tonsil,  Definition 7 

Anatomy 8 

Histology     9 

Special    Anatomy 12 

Surgical    Anatomy 19 

Chapter      III.    Physiology  of  the  Tonsil 22 

Chapter       IV.   Causes  of  Tonsil  Diseases 76 

Chapter         V.    Classification  of  Tonsil  Diseases.  ...  82 

Chapter       VI.   Adenoids    85 

Chapter     VII.   The  Tonsils  and  the  Teeth 106 

Chapter  VIII.  Six  Medical  Questions 119 

1.  Have   the   normal   faucial'  tonsils 

any  function  ? 119 

Addenda  from  original  sources  ...  125 
Addenda  showing  wide   diversity 

of   views 134< 

2.  What  are  they.^ 155 

'f^L  What  effects  are  directly  due  to 

their  removal.'' 160 

rf4.  )Have      phonetic      changes      been 

^-^     noted?    166 

5.  Would  you  advise  the  removal  of 

normal    tonsils  ? 174 

6.  Remarks?    178 

ix 


CONTENTS 


PAGE 

Chapter      IX.   The  Science  of  the  Vocal  Art 181 

Chapter        X.   Six  Voice  Questions 241 

1.  Are  the  normal  faucial  tonsils  of 

any  use  to  singers? 241 

Addenda .;....    246 

2.  HoWj    or    in    what    manner,    are 

,^       they  of  use  to  singers  ? 248 

-^.  Do  you  know  of  any  instances  in 

which  the  voice  was  improved 

/^A       after  their  removal? 251 

\^  Do  you  know  of  any  instances  in 
which  the   voice  was   impaired 

;-N         or  ruined  after  their  removal?.  256 
'  §r.  Is    removal    of    tonsils    advisable 

in  singers  ? 259 

6.   Remarks  ?    265 

Chapter       XI.     Diagnosis  of  Tonsil  Diseases 272 

Chapter     XII.     Hygiene  of  Tonsils  and  of  Voice.  .  .  .  306 

Hygiene  of  Tonsils 306 

Hygiene  of  the  Voice 310 

Chapter  illl.     Treatment  of   Tonsils 328 


ILLUSTRATIONS 


1  Portrait  of  the  Author Facing  Title  Page 

2  Plate  showing  position  of  the  tonsils  .  .  .  Facing  Page       9 

3  The  vowel  siren  and  buccal  resonators. 

Marage    "  "       181 

4  Photographs  of  the  voice  in  singing  the 

same  exercise.     Marage    "  "       193 

1.  French  method. 

2.  Italian  method. 

5  Molds  of  the  buccal  cavity  pronouncing 

the  vowels.    Marage "  "       195 

6  Photographs    of   the   voice    in   singing 

and  speaking.     Marage "  "      209 

1.  Speaking. 

2.  Singing. 

7  Photographs   of   the   voice   in   medical 

practice.    Marage "  "      211 

1.  Singer's  nodule. 

2.  Pharyngeal   catarrh. 

8  Facsimile  letter  of  Signor  Lamperti.  .  .       "  "      241 

9  Vertical  section  of  nose,  pharynx  and 

larynx "  "       307 

10  Facsimile  letter  of  Mme.  Adelina  Patti 

(Baroness  Cedarstrom) "  "      389 


CHAPTER  I 
RESEARCH  INVESTIGATION. 

Research  investigation  lays  bare,  explains  and 
connects  the  facts  which  form  the  foundation  of 
every  science. 

Science  is  the  knowledge  of  ascertained  facts, 
arranged  in  orderly  series,  and  referred  to  gen- 
eral truths  and  principles  on  which  it  is  founded. 
Science  is  a  record  of  truths.  Science  accepts  no 
statement  as  one  of  fact,  unless  its  truth  can  be 
proved  from  every  possible  point  of  view. 

The  man  with  facts  is  an  authority.  The  man 
without  facts  is  no  authority.  Every  fact  ascer- 
tained is  a  scientific  asset,  and  adds  one  unit  to 
the  sum  total  of  human  knowledge.  Knowledge 
is  power.  The  educated  physician  of  to-day  is  a 
man  of  broad  culture  and  trained  in  the  funda- 
mental sciences  that  underlie  medicine;  he  has  a 
good  knowledge  of  the  history  of  medicine  and 
of  the  means  by  which  advances  have  been  made. 
He  knows  the  past  and  looks  into  the  future. 
He  is  familiar  with  the  results  of  modern  scien- 
tific research,  and  is  able  to  maintain  the  dignity 
of  a  learned  profession.  He  knows  that  medical 
and  surgical  science  are  inseparable,  that  preven- 
tive surgery  is  identical  with  preventive  medicine 
as  the  great  aim  of  modern  medical  research ;  that 
operative  surgery  and  practical  medicine  have 
the  same  object,  namely:  the  restoration  of  phys- 
iological function.  The  complete  restoration  of 
physiological  function  is  ideal  surgery. 

The  prevention  of  small-pox  by  vaccination; 


2  THE    TONSILS    AND    THE    VOICE 

the  cure  of  diphtheria  by  antitoxin;  the  cure  of 
lock-jaw  and  of  hydrophobia  by  the  injection  of 
serum;  the  discovery  of  the  germ  of  Asiatic 
cholera,  of  the  bacillus  of  tuberculosis,  of  leprosy, 
and  of  epidemic  infantile  paralysis ;  the  discovery 
of  the  mosquito  as  the  cause  of  yellow  fever  and 
malaria,  and  the  prevention  of  these  diseases  by 
the  destruction  of  the  breeding  places  of  these  in- 
sects, are  examples  of  the  value  of  modern  medi- 
cal research. 

The  discovery  of  the  action  on  the  blood  vessels 
of  the  secretion  of  the  suprarenal  gland;  the  re- 
markable mental  and  physical  improvement  of 
backward  and  defective  children  by  the  adminis- 
tration of  the  extract  of  the  thyroid  gland;  and 
the  fact,  as  stated  by  Sajous,  in  his  great  work 
on  "The  Internal  Secretions,"  that  "the  vermi- 
form appendix  is  not,  as  now  taught  in  text- 
books, a  functionless  structure  of  low  vitality,  but 
that  it  secretes  a  relatively  large  quantity  of  suc- 
cus  entericus  containing  auto  antitoxin  to  insure 
asepsis  of  the  appendix,  and  of  the  caecal  cavity 
particularly  exposed  to  the  accumulation  of 
putrefactive  material,"  are  further  examples  of 
the  benefits  of  research  investigation. 

Recent  research  has  enriched  our  knowledge  in 
physiologico-acoustics  and  in  the  mechanism  of 
voice  production.  The  doctrine  of  ages  that  the 
human  voice  was  produced  by  a  stringlike  vibra- 
tion of  the  vocal  chords  is  disproved  and  aban- 
doned. 

The  mechanism  of  production  of  vowel  sounds, 
and  the  photographing  of  the  human  voice  where- 
by the  voice  teacher  is  enabled  to  demonstrate 


RESEARCH    INVESTIGATION  3 

good  voices  from  bad  and  also  to  illustrate  the 
progress  of  the  pupil  in  tone  production,  and 
whereby  the  physician  is  enabled  to  show  by 
means  of  photographs  the  correctness  of  his  diag- 
nosis in  voice  complaints,  are  new  lines  along 
which  research  studies  have  extended. 

The  re-education  of  the  hearing  in  cases  of 
sclerotic  deafness  is  another  interesting  advance. 

In  every  science,  art  and  industry,  energies  are 
strained  in  the  pursuit  of  original  research. 
George  Crocker's  legacy  to  Columbia  University 
of  more  than  six  hundred  thousand  dollars,  for 
the  sole  purpose  of  research  investigation  into  the 
cause  and  prevention  of  cancer,  indicates  a  deplo- 
rable absence  of  knowledge  upon  this  subject. 

The  causation  of  tumors  needs  investigation. 
Every  field  of  medical  science  is  in  urgent  need 
of  the  light  of  scientific  research. 

Many  questions  concerning  the  tonsils  await 
the  light. 

What  is  a  normal  tonsil? 

Has  the  normal  faucial  tonsil  any  function? 

Has  it  an  internal  secretion? 

Is  it  a  protective  organ? 

What  is  the  object  of  the  system  of  closed  lym- 
phatic canals  that  occupy  the  follicles  of  the  ton- 
sil? 

What  is  the  cause  that  leads  to  the  constant  ap- 
pearance of  the  strong  fibro-aponeurotic  sheath 
that  encases  the  faucial  tonsil  like  an  armor-plate, 
unperf orated  by  blood  vessel,  nerve  or  lymphatic  ? 

What  function  is  served  by  this  fibro-muscular 
capsule  that  its  growth  becomes  a  necessity? 

Has  the  tonsil  a  mechanical  function? 


4  THE    TONSILS    AND    THE    VOICE 

Has  it  a  phonetic  function? 

Has  the  normal  tonsil  any  influence  on  the 
voice,  in  singing  or  speaking? 

M.  Hicguet,  in  presenting  his  research  report 
to  the  Societe  Beige  D'Otologie,  De  Rhinologie 
et  De  Laryngologie,  on  the  ''Function  and  Util- 
ity of  the  Palatine  Tonsil''  stated  that  "the  diver- 
sity of  theories  which  he  had  met  with  in  his  work 
had  put  him  to  much  pains  to  form  the  conclu- 
sions at  the  end  of  his  report;  and  he  explained 
why  he  is  not  enthusiastic  about  any  of  them." 

I  have  made  a  research  investigation  concern- 
ing the  functions  of  the  f aucial  tonsil.  My  first 
inquiry  brought  this  answer,  "If  you  will  define 
what  you  mean  by  a  normal  tonsil,  I  will  be 
pleased  to  reply."  Therefore,  a  definition  of 
what  constitutes  a  normal  tonsil  became  at  once  a 
necessity.  My  definition  is  arbitrary,  but  was 
essential  as  a  base  for  inquiries. 

yiy  inquiries  were  sent  to  every  professor  of 
physiology,  physiological  chemistry,  biology, 
pathology,  bacteriology  and  laryngology  in  the 
world  of  whom  I  had  any  knowledge.  Some  an- 
swered categorically ;  some  said  that  they  had  no 
knowledge;  some  sent  literature;  some  made  no 
reply.  I  also  addressed  all  of  the  most  noted 
voice  physicists,  voice  trainers  and  voice  users. 

The  highest  authorities  expressed  personal  in- 
terest in  my  work,  and  they  contributed  with  the 
greatest  detail. 

Professors  Frankel,  Marage,  Brieger,  Von 
Levinstein,  Von  Gutzmann,  Jacobi,  Raoult  and 
others  courteously  sent  me  copies  of  their  original 
works,  in  place  of  routine  answers. 


RESEARCH    INVESTIGATION  5 

And  still  others  sent  me  personal  communica- 
tions, not  for  publication  but  containing  views  of 
such  general  interest  as  to  induce  me  to  overstep 
just  enough  to  permit  these  convictions  to  become 
known  without  divulging  the  privacy  of  their 
authorship. 

Among  others,  I  received  the  following  replies, 
from  professors  in  Columbia  University,  Har- 
vard, Pennsylvania,  Johns  Hopkins,  McGill  and 
other  universities: 

"I  have  delayed  answering  your  letter  until  I 
might  consult  with  some  of  our  younger  laryn- 
gologists  thinking  that  they  might  help  you.  I 
find  though,  from  what  they  tell  me,  that  their 
facts  as  regards  the  physiology  of  the  faucial  ton- 
sil are  too  meager  to  be  of  any  real  service, 
though  they  admit  that  occasionally  there  is  re- 
moval of  what  are  subsequently  found  to  be  his- 
tologically normal  tonsils." 

"There  is  at  present  a  startling  onslaught  upon 
the  tonsils,  which  often  passes  the  bounds  of 
reason.  Whether  the  present  attitude  of  the 
profession  results  in  more  good  or  harm  I  do  not 
know,  and  I  hope  that  you  will  find  out." 

"I  feel  that  it  means  much  to  know  when  not  to 
operate  upon  the  tonsils.  And  we  must  if  pos- 
sible know  their  function  and  the  evils  of  sacri- 
ficing that  function." 

"I  am  very  glad  to  know  that  you  are  investi- 
gating this  subject,  because  I  believe,  as  the  re- 
sult of  my  own  observation,  that  there  is  alto- 
gether too  much  operative  procedure  in  relation 
to  these  important  organs." 

"Particularly  in  nose  and  throat  work  there  has 


6  THE    TONSILS    AND    THE    VOICE 

been  published  a  lot  of  fake  work  which  is  simply 
a  matter  of  personal  advertisement  for  the 
author,  and  it  is  beneath  the  contempt  of  the  pro- 
fession to  further  countenance  it." 

"Nothing  offends  me  more  than  the  indiscrimi- 
nate tonsillar  slaughter  that  is  just  now  having 
what,  I  hope,  will  be  a  very  short-lived  vogue, 
and  I  am  exceedingly  glad  that  your  voice  has 
been  added  to  those  'discordant'  ones  of  which 
that  of  Lermoyez  is  an  encouraging  example." 

"It  seems  pathetically  strange  to  me  that  so 
many  educated  and  experienced  men  can  be  led 
so  easily  and  so  far  astray  from  the  paths  of 
common  sense  surgery  and  pathology  by  the  hue 
and  cry  of  a  lot  of  raw  and  unbalanced  fanatics." 

"I  have  done  many  hundreds  of  tonsillotomies, 
never  a  tonsillectomy.  I  agree  with  Chiaris 
terse  statements.  I  hope  the  'ectomy'  fad  will 
soon  be  buried  without  mourners." 

The  authorities  at  the  above  mentioned  univer- 
sities, from  whom  I  received  the  foregoing  re- 
sponses, evidently  do  not  grant  carte  blanche 
permission  to  their  students  for  the  promiscuous 
performance  of  tonsillectomy. 

Among  the  hundreds  whom  I  addressed,  only 
one  medical  professor  refused  to  answer,  and  just 
one  singing  teacher  took  time  to  write  (from 
Paris)  that  she  had  not  time  to  reply. 

As  a  result  of  my  research,  I  will  present  some 
facts  that  show  an  important  relationship  of  the 
faucial  tonsils  with  science,  surgery,  speech  and 
song. 


CHAPTER  II 
ANATOMY  OF  THE  TONSIL. 
THE    NORMAL    FAUCIAL    TONSIL. 

In  the  pursuit  of  my  research  into  the  physi- 
ology of  the  faucial  tonsil,  it  was  necessary  to  de- 
fine what  I  meant  by  a  noi'm  al  organ,  in  order  that 
responses  might  be  based  upon  identical  condi- 
tions. 

No  complete  or  satisfactory  definition  of  a  nor- 
mal faucial  tonsil  is  to  be  found  in  any  textbook. 

DEFINITION.  By  the  term,  normal  fau- 
cial tonsil,  I  mean  the  tonsil  situated  in  the  fau- 
ces, between  the  anterior  and  the  posterior  pala- 
tine arches,  in  healthy  condition,  and  of  such  size 
as  not  to  project  beyond  the  lines  of  the  palatine 
arches,  nor  press  upon  surrounding  tissues,  of  a 
size  so  small  as  not  to  interfere  with  the  perfect 
anatomical  outlines  of  the  walls  of  the  pharynx. 
Upon  this  definition  my  inquiries  were  made,  and 
responses  received  from  Von  Schr otter.  Von 
Chiari,  Schviiegelow,  Earth,  Escat,  Moure,  Cas- 
tex,  Luc,  Van  Baggen,  Luhet-Barhon,  JLer- 
moyez,  Massei,  St.  Clair  Thomson,  Gleitsniann, 
Miller,  Loewenherg,  Mackenzie,  Gleason, 
Holmes,  Casselherry,  Laniperti,  Sehastiani, 
Shakespeare,  De  Reszke,  Lehmann,  Sabatini, 
Cappiani,  Mott,  Curry,  White,  Rogers,  Von 
Klenner,  Sweet,  Rice,  Hubbard,  Schumann- 
Heink,  Nordica,  Tetrazzini,  Bond,  Bispham,  and 
others. 

My  definition  therefore  having  been  accepted 


8  THE    TONSILS    AND    THE    VOICE 

and  responded  to,  may  he  considered  as  a  reason- 
able definition  of  a  norinal  faucial  tonsil. 

Loewenberg  says :  "By  normal  tonsils,  I  mean 
tonsils  of  a  healthy  color,  those  not  enlarged  in 
length  or  thickness,  and  showing  no  evidences  of 
chronic  inflammatory  processes." 

Semon  speaks  of  "tonsils  projecting  under 
normal  conditions  nearly,  or  quite  up  to,  or  even 
a  little  beyond  the  palatine  arches." 

The  question  of  determining  what  is  a  normf^l 
tonsil  is  no  longer  difficult. 

THE  NORMAL  TONSIL  possesses  a  nor- 
mal histologic  structure.  The  microscope  will 
determine  this  without  question.  Tonsils  of  nor- 
mal structure  vary  in  size,  in  different  persons. 
A  large  tonsil  in  a  large  mouth  is  as  natural  as  a 
small  tonsil  in  a  small  mouth.  A  tonsil  of  normal 
histologic  structure  may  be  of  abnormal  size;  it 
may  be  so  large  as  to  interfere  with  the  natural 
functions  of  the  pharynx,  or  it  may  be  too  small 
to  properly  perform  its  own  functions. 

ANATOMY  OF  THE  TONSIL.  The 
anatomy  of  the  tonsil  becomes  more  important  as 
research  progresses.  Formerly,  the  word  "ton- 
sil," meant  the  faucial  tonsil;  the  organ  which 
Escat  and  other  continental  ^vriters  name  the 
palatine  tonsil.  But  in  the  light  of  modern  re- 
search, the  term  tonsil  is  now  used  to  designate 
various  collections  of  lymphoid  structures  that 
exist  in  the  post  nares,  pharynx,  larynx,  and  at 
points  throughout  the  alimentary  canal ;  so  that  it 
now  becomes  necessary  to  specify  the  particular 
tonsillar  organ  to  which  you  refer,  as  the  pharyn- 
geal tonsil,  the  faucial,  the  lingual,  the  laryngeal. 


|J1\ Hard  Palate. 

'^\l*^l\       Soft  Palate. 


Pharynx. 
Tongue. 


Plate  showing  position  of  the  tonsils. 


ANATOMY    OF    THE    TONSIL  9 

and  so  on.  Without  this  distinction,  it  is  impos- 
sible to  discuss  intelligently  the  subject  of  tonsils, 
because  these  organs,  while  identical  in  histologi- 
cal structure,  are  not  identical  in  their  gross  anat- 
omy. Neither  are  they  identical  in  their  physio- 
logical function. 

A  remarkable  anatomical  formation  is  Walde- 
yer's  lymphatic  ring  (described  in  works  on  anat- 
omy), consisting  of  the  two  faucial  tonsils,  the 
two  tubal,  the  lingual,  and  the  pharyngeal  tonsil, 
the  last  of  which  is  sometimes  unfortunately 
called  ''adenoids."  Connected  with  Waldeyer's 
ring,  there  is  another,  a  secondary  ring,  formed  of 
similar  hut  smaller  bodies:  and  yet  beyond  this 
secondary  ring  there  are  countless  thousands  of 
still  smaller  bodies,  microscopical  in  size,  scat- 
tered about  in  the  post  nares,  mouth,  pharynx  and 
larynx. 

HISTOLOGY.— The  histological  constitu- 
tion is  the  same  for  all  the  pharyngeal  lymphoid 
tissue.  The  pharyngeal,  tubal,  lingual  and  fau- 
cial tonsils  are  absolutely  identical  in  their  histo- 
logic constitution.  Koelliker,  Luschka  and  Frey 
have  proved  these  observations.    (Mar age.) 

The  organs  of  the  Waldeyer's  ring  consist 
mainly  of  what  Frdnkel  calls  nodules  and  tonsils. 
He  defines  a  tonsil  as  "an  organism  surrounded 
by  connective  tissue  which  consists  of  adenoid  tis- 
sue with  genuine  follicles  around  the  fossula. 

"Formerly  large  pockets  in  the  tonsils  were 
called  follicles,  but  the  Anatomical  Society  now 
calls  the  large  cavity  a  fossula,  and  has  reserved 
the  name  follicle  for  the  microscopic  formations. 

"The    nodule    is    a  conglomeration    of    lym- 


10  IHE    TONSILS    AND    THE    VOICE 

phatic  tissue  with  genuine  follicles.  The  smaller 
noduli  are  discriminated  from  the  tonsils  by  hav- 
ing a  smaller  fossula  and  are  less  complicated  in 
structure.  In  the  pharyngeal  tonsil  the  fossulae 
are  not  as  straight  and  simple  as  in  the  faucial." 
(Frdnkel.) 

"Lymph  nodes  are  structures  so  placed  in  the 
course  of  the  lymph  vessels  that  the  lymph,  in 
flowing  toward  the  larger  central  tnmks,  passes 
through  them,  undergoing  a  sort  of  filtration  as 
it  percolates  through  the  traheculae  of  the  lymph 
sinuses.  There  is  considerable  variation  in  the 
situation,  number  and  size  of  lymph  nodes,  in 
special  regions  of  the  body."  (Dela field  and 
Prudden.) 

These  bodies,  according  to  size,  may  be  desig- 
nated as  tonsils,  nodes  and  nodides. 

Von  Levinstein  "considers  the  tonsil  to  he  an 
organ  which  consists  of  a  number  of  lymphatic 
nodides,  between  which  there  is  a  variable  amount 
of  tissue  [which  latter  in  case  of  a  hyperplasia  of 
the  organ,  also  shows  adenoid  character.)'' 

In  the  faucial  tonsil  ten  or  twelve  round  or 
oval  nodules  are  rather  regularly  grouped  imme- 
diately  below  the  walls  of  the  fossulae.  They 
consist  of  an  extremely  delicate  reticulum  of  con- 
nective tissue.  The  lymph  nodules  surround  a 
number  of  fossulae.  These  fossulae  are  lined  by 
a  mucous  membrane  having  the  ordinary  func- 
tions of  other  mucous  membranes  so  far  as  known. 

"'Stohr  states  that  small  gaps  exist  between  the 
normal  epithelium  of  the  surface  of  the  tonsil 
crypts,  but  Frdnkel  and  other  distinguished  in- 
vestigators den}^  this  statement."     (Levinstein.) 


yVNATOMY    OF    THE    TONSIL  H 

"When  we  remove  a  particle  of  muciiis  from 
the  surface  of  the  tonsil  of  a  person  in  good 
health,  we  always  find  that  it  contains  leucocytes, 
especially  microphages,  filled  with  micro-organ- 
isms of  all  kinds."     (Metchnikoff.) 

"The  lingual  tonsil  sometimes  overlaps  and 
blends  with  the  faucial  tonsil.  The  lingual  ton- 
sil atrophies  at  fourteen  years  of  age,  and  after  it 
has  disappered,  the  base  of  the  tongue  becomes 
carpeted  over  with  adenoid  follicles."  (Escat, 
Moure.) 

Von  Levinstein  says :  "We  find  a  great  many 
mucous  glands  in  the  nearest  surrounding  neigh- 
borhood of  the  pharyngeal  tonsil,  and  that  these 
glands  mainly  send  their  exits  not  through  the 
substance  of  the  tonsils  to  their  surface,  but 
rather  directly  to  the  surface  of  those  organs  to 
which  they  belong — the  soft  palate  and  the  fau- 
cial arches.  To  further  illustrate  this  observa- 
tion, I  have  shown  that  the  group  of  acinous  mu- 
cous glands,  in  the  well-known  figure  by  Luschka 
of  the  faucial  tonsil,  does  not  belong  to  the  fau- 
cial tonsil  proper^  but  to  its  neighborhood.  Be- 
sides I  have  described  the  tonsil  where  it  is  impor- 
tant to  observe  that  a  great  many  mucous  glands 
send  their  channels  into  the  fossula  of  this  organ 
— the  tonsilla  laryngis. 

"The  anatomical  structure  of  the  faucial  and 
pharyngeal  tonsils  contradicts  the  theory  that  the 
object  of  these  tonsils  should  be  to  produce  a 
slimy  secretion." 

"The  anatomical  picture  of  the  ordinary  lym- 
phatic gland  differs  absolutely  from  that  of  the 


12  THE   TONSILS   AND   THE   VOICE 

tonsils.  Aside  from  the  fact  that  the  ratio  of 
connective  tissue  and  adenoid  tissue  in  both  or- 
gans is  different,  there  also  are  missing  in  the 
lymphatic  glands,  especially  those  organs  which 
give  to  the  tonsil  its  characteristic  structure,  the 
fossula.  Therefore,  we  can  never  identify  the 
tonsil  as  simply  glands,  but  we  have  to  consider 
them  as  different  organs." 

SPECIAL  ANA  TOMY.  The  faucial  tonsil 
has  remarkable  anatomical  characteristics  not 
possessed  by  the  pharyngeal  and  other  tonsils. 

( 1 )  Regarding  situation.  It  occupies  an  ana- 
tomical situation  quite  segregated  from  the  other 
bodies  that  compose  the  Waldeyefs  ring.  Be- 
cause of  this  segregation,  and  the  possession  by 
this  tonsil  of  many  features  not  possessed  by  any 
other  body  in  the  ring,  it  might  well  be  separated 
from  ring  consideration. 

(2)  Regarding  surroundings,  (a)  ''There 
are  no  lymphatic  sinuses  around  the  tonsil." 
(Retterer,  Labbe  and  Sirugue,  Hodenpyl, 
Most.) 

(b)  "The  lymph  current  near  the  tonsil  is  less 
active  than  that  of  the  pharynx  at  some  distance." 
(Labbe,  Hodenpyl.) 

(c)  "Injections  made  into  the  neighborhood 
of  the  tonsil  (not  even  into  the  tonsil  itself)  do 
not  spread  like  those  made  into  other  parts  of  the 
nasopharynx."  {Retterer,  Labbe  and  Sirugue, 
Hodenpyl,  Most,  Jacobi.) 

"In  cases  of  membranous  throat  disease  (diph- 
theria) ,  whenever  the  membrane  is  limited  to  the 
tonsil  there  is  little  or  no  glandular  swelling  in 
the  neighborhood,  nor  constitutional  symptoms. 


ANATOMY   OF    THE    TONSIL  13 

It  would  therefore  appear  that  the  tonsil  and  its 
immediate  neighborhood  are  rather  inferior,  in 
regard  to  facilities  for  absorption  to  the  rest  of 
the  pharynx  and  nares."     (Jacohi.) 

Hodenpyl  "found  that  the  tonsils  in  a  normal 
condition  absorb  neither  liquid  nor  solid  particles 
from  the  oral  cavity." 

(f)  ^^The  group  of  acinous  mucous  glands  in 
the  well-known  figure  hy  Luschka  of  the  faucial 
tonsil^  does  not  belong  to  the  faucial  tonsil,  hut  to 
its  neighborhood."     (Levinstein.) 

(g)  "The  function  of  secreting  mucus  does  not 
belong  to  the  faucial  tonsil,  but  to  the  glands  in 
groups  outside  of  it."     (Labbe  and  Sirugue.) 

(h)  "The  greater  part  of  the  lymph  vessels 
are  efferent,  the  smaller  afferent."     (Groher.) 

(i)  "It  has  not  been  proved,  and  it  will  be  very 
difficult  to  prove,  because  it  is  impossible  to  say 
from  the  histologic  picture,  which  are  the  afferen- 
tia  and  which  the  efferentia  lymphatic  vessels  of 
the  tonsil."     (Levinstein.) 

(3)  Regarding  external  surface.  (a)  The 
external  deep  surface  of  the  faucial  tonsil  is  en- 
cased in  a  firmly  adherent,  strong,  fibrous  sheath. 
Nothing  like  this  capsule  surrounds  any  other 
lymphatic  body. 

(b)  "Contracting  muscular  fibres  are  inserted 
into  the  sheath  derived  from  the  superior  con- 
strictor muscle  of  the  pharynx."  (Koelliker,  Ja- 
cobi.  Sett.) 

I  am  forced  to  believe  that  the  strong  musculo- 
fibro-aponeurotic  sheath,  that  covers  the  faucial 
tonsil,  deserves  more  serious  consideration  than  it 


14  THE    TONSILS    AND    THE    VOICE 

has  yet  received  from  anatomists  and  physiolo- 
gists. 

So  dense  and  tendinous  and  strongly  adherent 
is  this  capsule  that  one  may  consider  the  organ  as 
being  armor-plated. 

(c)  It  is  not  perforated  by  lymphatics,  nerves, 
arteiies  or  veins. 

(d)  "The  sheath  sometimes  sends  a  network  of 
fibrous  tissue  as  outrunners  along  the  walls  of  the 
blood  vessels  which  prevents  them  from  readily 
contracting  after  being  cut."  (Hodenpyl,  Ja- 
cobi.) 

(e)  "The  sheath  sends  connective  tissue  into 
and  between  the  folds  of  the  mucosa.''    (Jacobi.) 

(f)  "Thick  or  thin,  the  fibrous  sheath  is  firm 
and  solid.  That  is  why  abscesses  of  the  tonsil  do 
not  open  into  the  maxillopharj^ngeal  space." 
(Jacobi.) 

(g)  This  dense  covering  of  musculo-fibro- 
aponeurotic  structure  cannot  be  looked  upon  as 
an  atavism;  7ior  is  it  conceivable  to  view  this  con- 
stant and  definite  structure  that  envelops  the 
tonsil,  receives  muscular  fibres  from  the  superior 
constrictor  muscle,  extends  its  fibrous  outrunners 
along  the  walls  of  the  blood  vessels  that  run 
through  the  body  of  the  organ  and  sends  its  con- 
nective tissue  into  and  between  the  folds  of  the 
mucosa  as  a  simple  anatomical  accident.  These 
features  are  too  constant  to  allow  such  interpreta- 
tion. 

Is  it  not  reasonable  to  think  that  the  develop- 
ment of  the  strong,  musculo-fibro-aponeurotic 
sheath  is  a  result  of  evolution  to  meet  some  phy- 
siological demand? 


ANATOMY    OF    THE    TONSIL  15 

The  sheath'  of  the  tonsil  is  always  present. 
There  must  he  some  strong  physiological  reasons 
for  the  existence  of  this  powerful  anatomical  con- 
trivance. 

What  are  they?  Have  the  muscular  fibres 
that  enter  the  sheath  no  use?  Why  does  the 
sheath  send  fibrous  outrunners  along  the  walls 
of  the  blood  vessels  and  into  the  folds  of  the 
mucosa?  Is  swelling  of  the  tonsil  ever  similar 
to  that  of  erectile  tissue  ?  Or  ever  due  to  muscular 
action  ? 

Von  Chiari,  Moure,  Frank  E.  Miller,  Escat 
and  others  advise  against  the  removal  of  the 
sheath  in  voice  users. 

(h)  Smaller  nodules  differ  from  the  tonsil  by 
having  a  smaller  fossula,  and  less  complicated 
structure. 

( i )  ''The  fossulae  of  the  faucial  tonsil  are  more 
straight  and  simple  than  those  of  the  pharyngeal 
tonsilJ"     [Frdnkel,  Levinstein.) 

(j)  The  organ  is  of  cartilaginous  consistence 
and  somewhat  compressible. 

(k)  The  anatomical  position  of  the  organ  is 
notable  amidst  a  framework  of  muscles.  It  is 
both  compressible  and  movable.  It  changes  posi- 
tion both  in  swallowing  and  in  phonation.  In 
swallowing  the  palato-pharyngeus  muscle  draws 
the  palate  down  upon,  and  the  tonsil  in  upon  the 
food,  to  force  it  downward.  The  tonsil  is  also 
pressed  inward  in  the  act  of  swallowing  by  the  su- 
perior constrictor  and  drawn  inward  by  the  pala- 
to-glossus.  There  is  a  ceaseless  and  probably  in- 
determinate, though  important  play,  upon  the 
faucial  tonsils,  by  many  muscles,  in  speaking  and 


16  THE   TONSILS   AND   THE   VOICE 

in  singing.  The  faucial  tonsil  has  probably  more 
mechanical  than  physiological  functions, 

I  consider  it  highly  important  to  note  that 
while  the  faucial  tonsil  changes  with  age  in  char- 
acter^ size,  shape  and  consistence,  it  never  disap- 
pears, but  always  remains  to  give  to  the  walls  of 
the  pharynx  a  needed  solidity.  The  faucial  tonsils 
resemble  the  cartilages  of  the  larynx  and  trachea. 
But  they  are  softer.  The  anatomical  and  func- 
tional advantages  of  the  firmness  they  impart  to 
the  pharyngeal  wall,  may  be  readily  conceived. 
They  serve  a  purpose  that  hard,  unyielding  osse- 
ous formations  would  not  serve.  They  are  mo- 
bile, and  compressible:  and  by  multiple  move- 
ments and  innumerable  re-adjustments  in  posi- 
tion, have  undoubted  influence  and  effects  upon 
the  acoustics  of  the  oral  cavity,  and  upon  the  reso- 
nance and  timbre  of  the  voice. 

(4)  Regarding  Internal  Structure,  (a)  The 
vascularity  of  the  faucial  tonsil  is  slight. 

(b)  "The  periphery  of  the  lobules  is  more  vas- 
cular than  the  centers."  (Retterer,  Labbe.) 

(c)  "It  has  little  or  no  connection  with  neigh- 
boring lymphatics,  through  its  surface."  Grober 
demonstrated  the  comparative  absence  of  a  direct 
communication  of  the  tonsil  with  the  rest  of  the 
body  through  the  surrounding  fibrous  capsule. 
His  injections  of  the  tonsils  accumulated  in  large 
quantities  under  the  capsule.  Thus  it  happened 
that  the  organ  was  often  enlarged  to  a  consider- 
ible  extent.  The  adipose  tissue  surrounding  the 
;onsil  seems  to  be  rather  devoid  of  lymph  vessels. 

(d)  Von  Lenart  has  proved  the  existence  of  a 
iirect  communication  betwen  the  lymphatic  ves- 


ANATOMY    OF    THE    TONSIL  17 

sels  of  the  nose  and  of  the  tonsil;  and  also  of  a  di- 
rect communication  between  the  two  f  aucial  ton- 
sils. 

( e )  Retterer,  Krause,  Lahbe  and  Sirugue,  and 
Hodenpyl^  have  proved  the  existence  of  a  capil- 
lary network  of  lymphatic  vessels  occupying  the 
entire  follicular  mass  of  the  faucial  tonsil,  consti- 
tuting a  system  of  closed  lymphatic  canals  which 
do  not  open  into  the  connective  tissue  reticulum 
by  stomata  nor  by  gaping  extremities. 

(f )  Labbe  and  Sirugue  have  shown  the  origin 
of  these  lymphatic  vessels  in  the  reticulated  cov- 
ering, whete  they  are  represented  by  spaces,  not 
partitioned,  and  covered  by  an  endothelium. 
These  lymphatic  spaces  are  continued  by  the  cap- 
illaries and  the  lymphatic  vessels,  furnished  with 
a  complete  wall,  which  meet  each  other  in  the  con- 
junctive envelope  of  the  tonsil. 

(g)  ''Retterer  proved  the  existence  of  clear 
centers  in  the  follicles  of  the  tonsils,  but  did  not 
admit  their  identity  with  the  germinating  centers 
of  the  follicles  found  in  the  ganglions."  [Labbe 
and  Sirugue. ) 

(h)  "The  follicles  in  their  centers  have  a 
lighter  zone.  These  are  producing  centers,  be- 
cause the  production  of  lymphocytes  has  been  ob- 
served."    (Frdnhel. ) 

(i)  "The  germinative  centers  have  certainly 
the  same  functions  as  those  of  the  ganglions  which 
are,  as  Flemming  has  shown,  the  localities  for  the 
production  of  leucocytes.  There  is  in  the  germi- 
native centers  an  incessant  cellular  renovation." 
(Labbe  and  Sirugue.) 

(j)    "Ehrlich   and   Flemming   have   in   fact 


18  THE    TONSILS    AND    THE    VOICE 

shown  the  existence  of  several  kinds  of  leucocytes, 
upon  each  of  which  devolves  a  different  role,  a 
particular  function  in  the  defense  of  the  organism 
against  microbes  and  toxins."  {Labbe  and  Sirii- 
gue.) 

(k)  We  find  in  normal  faucial  tonsils  always 
follicles  with  cell  producing  centers. 

(1)  Retterer  proved  that  the  periphery  of  the 
lobules  is  more  vascular  than  the  centers. 

(m)    The  vascularity  of  the  organ  is  slight. 

(n)  The  nerve  terminations  in  the  tonsil  are 
not  well  known. 

The  faucial  tonsil  varies  in  not  only  size,  shape, 
consistency  and  color,  but  in  weight  and  general 
appearance.  It  varies  in  different  individuals, 
and  the  two  tonsils  often  vary  in  the  same  person. 
The  anatomical  characteristics  constantly  change 
from  infancy  to  old  age.  It  does  not  remain  for 
many  years  the  same ;  but  it  never  entirely  disap- 
pears. 

They  are  largest  from  three  to  eighteen  years 
of  age.  Not  so  large  under  three  j^ears.  After 
eighteen  years  of  age,  thej^  diminish  in  size,  their 
surface  becomes  smooth,  and  their  consistence 
firmer  and  more  cartilaginous.  They  frequently 
enlarge  and  annoy  during  childhood;  they  gen- 
erally cease  to  annoy  beyond  puberty. 

"Exposure  and  many  diseases,  change  the  sur- 
face and  the  structure  of  the  tonsils.  Cell  infil- 
tration and  cicatricial  tissue  render  absorption  less 
possible.  Blood  and  lymph  vessels  are  compressed 
and  undergo  atrophy.  That's  why  in  advanced 
life  the  tonsil  gets  harder  and  smaller,  and  infec- 
tions become  less."  (Jacohi.) 


ANATOMY    OF    THE    TONSIL  19 

The  more  highlj"  complex  tonsillar  tissue  oc- 
curs only  in  the  highest  type  of  animal  develop- 
ment. If  tonsils  have  no  physiological  function 
and  are  only  an  atavism,  they  likely  would  have 
disappeared,  instead  of  continuing  to  reappear,  in 
a  simple  form  in  the  lowest  vertebrate,  to  the  high- 
est and  most  complex  form  in  man. 

Surgical  Anatomy.  H ay mann  sa.ys:  "Opera- 
tions on  the  tonsils  are  looked  on  as  being  without 
danger.  However,  bad  results  do  occur.  Severe 
bleeding  may  follow  operations  on  the  tonsils. 
When  they  bleed  too  much,  they  call  them  hemo- 
philics." 

Mei'kel  says,  that  "the  veins  between  the  mus- 
cles of  the  pharynx  and  the  outer  fascia  form  a 
strong  irregular  network,  called  the  plexus 
pharyngeus.  Injuries  and  bleeding  from  this 
network  are  not  rare  in  excision  of  the  tonsils." 

Von  Chiari  mentions,  that  "in  some  cases  you 
can  see  at  the  side  walls  of  the  pharynx  a  large 
vessel  pulsating,  the  arteria  pharyngea  ascendens. 
In  such  cases  it  is  possible  to  injure  this  large  ves- 
sel." 

Dupuy  states,  that  he  "has  several  times  ob- 
served a  vessel  the  size  of  a  crow-quill,  super- 
ficially situated,  and  pulsating,  coursing  along 
the  juncture  of  the  posterior  and  lateral  walls  of 
the  pharynx."     I  have  seen  this  vessel. 

Angioma  of  the  base  of  the  tongue  is  common. 
Networks  of  varicose  veins  are  frequently  seen  at 
the  base  of  the  tongue  and  in  the  walls  of  the 
fauces  and  pharynx. 

Delavan  states,  that  "Both  carotid  arteries  are 
behind  the  faucial  tonsil,  the  internal  carotid  one 


20  THE    TONSILS    AND    THE    VOICE 

and  five-tenths  centimeters,  the  external  carotid 
two  centimeters,  distant  from  its  lateral  periph- 

It  is  not  uncommon  for  arteries  and  veins  to 
follow  anomalous  courses  and  to  be  found  out  of 
their  natural  positions.  The  vessels  in  the  neigh- 
borhood of  the  tonsil  form  no  exception  to  this 
statement.  In  fact,  the  internal  and  external 
carotids  with  their  branches  are  particularly 
crooked  and  irregular  in  their  courses. 

Gray  says,  that  "The  internal  carotid  artery  is 
remarkable  for  the  number  of  curvatures  that  it 
presents  in  different  parts  of  its  course." 

The  external  carotid  sometimes  curves  from  its 
regular  course  inwardly  toward  the  median  Hne 
behind  the  tonsil.  Branch  arteries  in  the  region 
of  the  tonsil  are  frequently  enlarged. 

"Abnormal  distribution  of  blood  vessels  is  a 
more  frequent  cause,  of  hemorrhage  than  hemo- 
philia," according  to  Barrell  and  Orr. 

"In  all  operations  upon  the  tonsil  we  should 
remember  the  close  proximity  of  the  internal  car- 
otid arteiy.  Instances  have  occurred  in  which 
this  artery  has  been  wounded  during  the  opera- 
tion of  scarifying  the  tonsil,  and  fatal  hemorrhage 
has  supervened."  (Gray's  Anatomy.) 

This  statement  is  repeated  in  each  and  all  edi- 
tions of  Gray's  Anatomy. 

In  the  17th  edition.  Gray  says,  "The  profuse 
bleeding  which  sometimes  follows  an  operation 
for  the  removal  of  the  tonsil  is  very  seldom  due  to 
injurj^  of  the  internal  carotid  but  to  injurj^  of  the 
ascending  pharyngeal  or  r-ne  of  the  palatine 
branches." 


ANATOMY    OF    THE    TONSIL  21 

"The  arteries  that  supply  the  tonsil,  from 
which  dangerous  bleeding  also  occurs,  are  the  dor- 
salis  linguae,  the  ascending  palatine,  and  the 
descending  palatine,  from  the  external  carotid." 

Schmiegelow  has  reported  the  case  of  an  im- 
mediate death  from  injury  of  the  carotid,  by  cur- 
ette, due  to  an  anomaly  in  its  course. 

William  H.  Pancoast,  at  his  Clinic,  at  the 
Medico-Chirurgical  College,  Philadelphia,  in  cut- 
ting out  a  tonsil  cut  the  internal  carotid  artery. 
( Reported  by  George  F.  Steveson. ) 

Treves,  in  his  Surgical  Anatomy,  reports  a  fa- 
tal accident  from  perforation  of  the  ascending 
pharyngeal  artery. 

Haymann  reports  injury  of  the  ascending 
pharyngeal. 

Haymann  says :  "If  the  cavity  of  the  mouth  is 
highly  arched  and  narrow,  injury  of  the  post 
nares  cannot  always  be  avoided  in  excising  the 
tonsils." 

"The  vomer  has  been  injured.  And  injury 
of  the  back  part  of  the  nasal  septum  may  cause 
severe  bleeding." 

"Zarniko  accidentally  cut  off  the  greater  part 
of  the  back  horns  of  the  turbinated  bones." 

Von  Chiari  states  that  "The  atlas  bone  may  be 
injured  in  enucleation  of  the  tonsil." 


CHAPTER  III 
PHYSIOLOGY  OF  THE  TONSIL. 

To  assign  a  physiological  role  to  an  organ, 
when  its  anatomy  has  not  been  clearly  defined,  is 
an  injudicious  and  dangerous  assumption.  The 
anatomy  of  the  triangles  of  the  neck,  or  of  the 
femoral  region  are  not  more  complicated  than  the 
anatomy  of  the  area  composing  the  pharynx ;  and 
the  physiology  of  the  pharyngeal  region  is  vastly 
more  complicated  than  that  of  any  other. 

The  anatomy  of  the  pharynx  is  not  thoroughly 
understood ;  and  its  physiology  remains  unsolved. 
On  account  of  the  great  difficulties  naturally  en- 
countered in  this  field,  as  for  example,  the  appar- 
ent impossibility  of  determining  the  action  of 
certain  muscular  fibres  that  always  become  lost 
in  their  final  distribution,  the  details  in  the  anat- 
omy and  physiology  of  the  phaiynx  may  never 
become  known.  Furthermore,  clinical  opportuni- 
ties will  rarely  be  numerous  enough  to  decide  the 
exclusive  or  partial  port  of  entry  of  a  specific 
germ  or  poison  into  the  circulation  from  the  phar- 
ynx, as  we  are  seldom  in  a  position  to  separate 
the  various  anatomical  structures  from  their 
neighbors  during  the  acute  invasion  or  the  rapid 
progress  of  a  microbic  or  toxic  poison. 

The  fauoial  tonsil  is  a  natural  organ.  Some 
questions  pertaining  to  its  physiology  are  settled. 
Judgment  upon  others  is  so  uniform  as  almost  to 
force  conviction ;  and  some  are  unsolved. 

In  the  determination  of  its  functions,  it  is  par- 

22 


PHYSIOLOGY    OF    THE    TONSIL  2a 

ticularly  necessary  to  carefully  separate,  and  to 
critically  examine,  the  different  anatomical  struc- 
tures composing  the  Waldeyer  lymphatic  ring. 
It  is  also  well  to  observe  the  anatomical  position 
of  the  f  aucial  tonsil,  and  its  relationship  to  neigh- 
boring organs. 

When  we  speak  of  the  f  aucial  tonsil,  we  must 
refer  alone  to  this  organ.  When  we  speak  of  the 
phaiyngeal  tonsil,  or  the  laryngeal,  we  must  not 
think  of  the  faucial,  for  these  three  tonsils  have 
different  functions.  And  when  we  speak  of  the 
Waldeyer  ring,  then  our  speech  must  represent  a 
composite  thought  of  composite  bodies  possessing 
varied  functions. 

SPEAK  ACCURATELY.  ASSUME 
NOTHING.  The  faucial,  pharyngeal  and 
laryngeal  tonsils  differ  in  their  functions  as  well 
as  in  their  structure.  Waldeyer's  lymphatic  ring 
is  an  important  and  complex  physiological  appa- 
ratus. 

The  ensemble  of  adenoid  bodies  composing  the 
Waldeyer  ring  situated  at  the  entrance  of  the  re- 
spiratory and  digestive  passages,  constitutes  the 
first  line  of  defense  against  microbic  invasion.  It 
is  composed  of  the  pharyngeal,  faucial,  lingual 
and  tubal  tonsils.  The  first  line  of  defense  is 
sustained  by  a  second,  represented  by  the  tribu- 
tary ganglions  of  all  the  pharyngeal  lymphatic 
network  so  well  presented  by  Escat,  in  his  work 
on  Les  Maladies  du  Pharynx. 

FUNCTION  OF  LYMPHATIC 
GLANDS.  The  function  of  the  lymphatic 
glands  is  to  act  as  a  sort  of  filter  for  the  lymph. 
Should  the  lymph  contain  any  foreign  substance 


24  THE    TONSILS    AND    THE    VOICE 

or  toxic  material,  these  tend  to  be  stopped  within 
the  gland,  not  only  on  account  of  the  anatomical 
peculiarities  of  the  structure,  but  also  on  account 
of  the  cellular  hyperplasia  that  results  from  the 
irritation.  This  barrier  action,  as  will  be  readily 
understood,  is  a  most  important  one.  The  lym- 
phatic glands  are  set  like  sentinels  to  guard  all 
the  orifices  and  channels  of  the  body.  This  func- 
tion of  the  glands  has  been  clearly  demonstrated 
by  Bizzozero,  Ruffer  and  Ribbert. 

Lymph  nodes  are  structures  so  placed  in  the 
course  of  the  lymph  vessels  that  the  lymph,  in 
flowing  toward  the  larger  central  trunks,  passes 
through  them,  undergoing  a  sort  of  filtration. 
If  this  fact  be  borne  in  mind  the  lesions  of  the 
lymph  nodes,  which  are  in  the  majority  of  cases 
secondary,  are  much  more  readily  understood. 

"Particles  of  pigment,  cells  from  malignant 
tumors,  dead  or  disintegrating  cells,  red  blood- 
cells,  bacteria,  etc.,  which  in  any  way  get  into  the 
lymph  vessels,  are  carried  along  until  a  lymph 
node  is  reached,  and  here  they  are,  in  part  at 
least,  deposited  among  the  trabeculae  of  the  si- 
nuses, or  are  taken  up  by  phagocytic  cells,  while 
the  lymph  passes  on  and  out  of  the  efferent  ves- 
sels." (Delafield  and  Prudden.  Teoot-hooh  of 
Pathology,  Eighth  Edition,  1907.) 

Some  years  ago  Stohr  demonstrated  that  the 
wall  of  the  intestine,  and  especially  the  tonsils 
and  other  lymphoid  organs,  "ire  traversed  by  an 
enormous  number  of  leucocy  t'es,  which  exercise  a 
kind  of  migration  towards  the  cavities  containing 
micro-organisms.  This  continual  and  normal 
condition  is  often  termed  Stohr^s  phenomenon. 


PHYSIOLOGY    OF    THE    TONSIL  25 

"When  we  remove  a  particle  of  mucus  from 
the  surface  of  the  tonsils  of  a  person  in  good 
health  we  always  find  that  it  contains  leucocytes, 
especially  microphages,  filled  with  micro-organ- 
isms of  all  kinds."  (Metchnikoff ,  Immunity  in 
Infective  Diseases,  1905.) 

"The  leucocytosis  of  infectious  diseases  may  be 
regarded  as  the  effort  of  the  blood-producing 
organs  to  protect  the  blood  and  tissues  by  means 
of  leucocytes  against  the  invasion  of  micro-organ- 
isms and  against  the  action  of  toxins  in  the 
circulation."     {Dela field  and  Prudden.) 

Of  the  protective  action  of  the  Waldeyer  ring, 
with  its  secondary  tributary  line  of  defense,  it  has 
been  said,  that  the  pathogenic  agent  must  then 
traverse,  theoretically,  two  stages  before  invading 
the  general  circulation,  the  one  pharyngeal,  the 
other  ganglionic.  This  apparatus  of  physiologi- 
cal defense  may  at  any  time  be  inferior  to  its 
task,  and  powerless  to  arrest  the  microbic  inva- 
sion and  the  toxaemia  either  by  reason  of  its  con- 
stitutional insufficiency  or  by  reason  of  the  exces- 
sive virulence  of  the  enemy  with  which  it  enters 
into  a  struggle. 

The  pharyngeal  tonsil  is  a  most  important 
organ  in  the  first  line  of  defense  of  the  system 
against  microbic  invasion. 

Hypertrophy  of  the  pharyngeal  tonsil  consti- 
tutes the  affection  commonly  known  under  the 
name  of  "adenoid growth"  The  process  of  pha- 
gocytosis long  sustained  will  bring  on  chronic 
hypertrophy. 

Enlargement  of  the  pharyngeal  tonsil  {"" ade- 
noids") being  due  to  an  increase  in  the  process  of 


26  THE    TONSILS    AND    THE    VOICE 

phagocytosis,  removal  of  this  organ  tvhile  in  the 
condition  which  represents  the  height  of  its  bac- 
tericidal energy  is  a  vital  mistake.  The  line  of 
defense  against  microhic  invasion  is  thereby 
broken. 

Westenhoffer,  in  a  most  exhaustive  research  on 
the  ''Pathological  Anatomy  and  the  Way  of  In- 
fection in  Spinal  Meningitis''  has  given  absolute 
proof  that  the  "infectious  germs  enter  the  or- 
ganism through  the  pharyngeal  tonsil  and  in  no 
other  way." 

"In  all  cases,"  he  says,  "the  pharynx  was  in  a 
condition  of  acute  swelling  and  inflammation. 
This  swelling  extended  in  all  cases  down  to  the 
pharyngeal  wall.  In  all  cases  the  orifices  of  the 
Eustachian  tubes  were  equallj^  swollen.  In  all 
cases  the  anterior  part  of  the  nose  was  free  from 
inflammation.  The  increased  mucus  secretion 
was  always  in  the  superior  7iasal  region,  never  in 
the  anterior  part  of  the  nose.  The  faucial  tonsil 
and  arches  appeared  to  be  reddened  or  swollen  in 
less  degree;  sometimes  hardly  at  all.  The 
phary7igeal  tonsil  is  swollen.  In  all  cases  this 
tonsil  was  in  a  state  of  acute  swelling  and  redness. 
I  believe  that  the  disease  germ  finds  its  entrance 
into  the  tissue  of  the  body  from  the  posterior 
naso-pharjTix,  es^Decially  from  the  pharyngeal 
tonsil.  /  have  in  cases  of  just  beginning  menin- 
gitis seen  where  the  disease  begins  and  it  always 
begins  at  the  hypophysis  just  above  the  sella  tur- 
cica. We  can  judge  from  this  that  the  menin- 
gitis infection  gets  there  through  the  sphenoidal 
body  or  via  the  blood  vessels  which  pass  from  the 
naso-pharynx  to  the  sella  turcica.     It  is  impor- 


PHYSIOLOGY    OF    THE    TONSIL  27 

tant  that  in  ten  cases  an  inflammation  of  the 
sphenoidal  cavities  has  been  seen."  (Westen- 
hoffer,  Berliner  Klinische  Wochenschrift,  June 
12,  1905.) 

Westenhoffer  has  proved  that  the  pharyngeal 
tonsil  and  the  adjacent  lymphatics  act  as  a  por- 
tal of  entry  for  the  germs  of  cerebrospinal 
meningitis.  He  considers  the  faucial  tonsil  as 
little  or  not  at  all  involved  as  a  port  of  entry  for 
the  particular  germs  of  cerebro-spinal  meningitis. 

He  "considers  the  pharyngeal  tonsil  to  he  a 
protective  organ,  active  as  a  barrier  to  the  en- 
trance of  germs,  through  the  process  of  phagocy- 
tosis, except  when  by  reason  of  extreme  virulence 
and  great  numbers  of  the  infective  germs  this 
protective  influence  is  overcome." 

The  pharyngeal  tonsil  as  we  have  now  seen  is 
a  protective  organ;  and  in  some  circumstances  an 
avenue  of  entrance  for  infective  germs,  a  filtra- 
tion organ  for  material  that  enters  by  way  of  the 
nasal  passages. 

Von  Levinstein  "has  described  the  tonsil  where 
it  is  necessary  to  observe  that  a  great  many  mu- 
cous glands  send  their  channels  into  the  f  ossula — 
the  tonsilla  laryngis.  The  function  of  this  tonsil 
consists  in  the  production  of  a  slimy  secretion  to 
keep  the  vocal  cords  limber." 

"Stohr  discovered  that  an  interrupted  immi- 
gration of  leucocytes  takes  place  from  the  follicle 
and  adenoid  tissue  through  the  epithelium  into 
the  fossulae  and  buccal  cavity.  The  phenomena 
described  by  Stohr  present  themselves  under  va- 
rious aspects:  sometimes  as  a  passing  of  poly- 
nuclear  leucocytes  through  the  epithelium,  some- 


28  THE   TONSILS   AND   THE   VOICE 

times  as  a  multiplication  of  epithelial  cells  caused 
by  irritation  of  the  mucosa.  And  finally  per- 
haps sometimes  of  the  penetration  of  some  lym- 
phocytes coming  from  the  reticulated  skin.  But 
in  all  these  hypotheses,  the  signification  of  the 
phenomena  is  identical;  it  is  always  a  phenome- 
non of  cellular  reaction,  having  for  its  aim  the 
defense  of  the  mucosa  against  the  invasion  of  mi- 
crobes which  vegetate  at  the  surface  of  the  tonsil. 
This  phenomenon  is  in  no  way  special  to  the  ton- 
sillar mucosa ;  it  is  produced  at  the  level  of  all  the 
mucosae  and  has  already  been  well  studied  and 
described  by  Cormil  and  Ranvier,  in  the  buccal 
mucosa."     {Labbe  and  Sirugue.) 

"There  is  in  the  germinative  centers  of  the  ton- 
sil an  incessant  cellular  renovation.  Stohr 
admits  the  passage  of  leucocytes  through  the  epi- 
thelium into  the  buccal  cavity."  (Labhe  and 
Sirugue, ) 

"The  phenomena  of  absorption  at  the  level  of 
the  tonsils  has  been  studied  experimentally.  In 
HodenpyVs  experiments,  the  epithelium  of  the 
tonsils  prevented  absorption,  which  only  becomes 
possible  if  it  is  destroyed,  or  if  the  substances  are 
introduced  under  the  epithelial  bed,  and  even 
under  these  conditions,  the  absorption  is  very 
slow.  Hodenpyl  experimented  with  fatty  sub- 
stances, powders  and  colored  solutions."  {Lab- 
be  and  Sirugue.) 

"The  epithelium  has  the  same  protective  role 
at  the  level  of  the  tonsils  as  at  the  level  of  the 
buccal  mucosa.     The  crypts  augment  its  extent." 

"Even  in  the  normal  state  the  epithelium  is 


PHYSIOLOGY   OF    THE    TONSIL  29 

always  more  or  less  irritated,  and  above  all,  at 
the  bottom  of  the  crypts  and  we  have  seen  that 
it  is  the  seat  of  the  incessant  phenomena  of  cellu- 
lar renovation.  This  epithelial  irritation  is  due 
to  the  presence  of  dust,  or  small  foreign  bodies 
which  penetrate  into  the  crypts;  it  is  due  above 
all,  to  the  existence  at  the  surface  of  the  tonsil  of 
pathogenic  microbes,  which  are  found  constantly 
in  the  normal  state.  These  microbes,  although 
in  the  crypts,  are  on  the  exterior  of  the  tonsil,  and 
it  is  the  defense  reaction  of  the  epithelium  which 
prevents  their  penetration." 

"It  is  only  where  the  epithelium  is  destroyed 
that  the  microbes  penetrate  and  in  such  cases 
they  rarely  pass  beyond  the  conjunctive  bed;  it  is 
only  in  the  case  of  the  complete  destruction  of 
the  epithelium  that  they  may  be  found  in  the 
follicle.  The  leucocytes  have  not  solely  a  pha- 
gocytic role,  in  regard  to  microbes,  but  they  de- 
stroy also  their  toxins  in  producing  antitoxins 
and  divers  substances;  nucleins  and  oxydases, 
which  have  positive  chemico-toxic  properties  in 
regard  to  white  corpuscles  and  exalt  their  vital- 
ity."    (Lahbe  and  Sirugue.) 

"Tubercle  bacilli  reach  the  lungs  by  the  bronchi 
or  via  the  blood  vessels.  Valland  claims  that  the 
infection  of  the  lungs  can  occur  via  the  tonsils 
and  infected  glands  of  the  neck.  Many  authors 
claim  that  healthy  tonsils  do  not  allow  the  en- 
trance of  bacteria."  {Groher,  Die  Tonsillen  als 
Emtrillspforten  filr  Krankheitsneger^  besondes 
filr  der  Tuberkelbazillus.) 

Acute  catarrh  of  the  tonsils  shows  increased 
infiltration  with  leucocytes,  which  causes  enlarge- 


30  THE    TONSILS    AND    THE    A'OICE 

ment  of  the  organs,  also  increased  amount  of 
lymph  in  the  intercellular  spaces. 

The  increased  exudate  is  an  agreeable  medium 
for  many  parasites,  therefore  inflamed  tonsils 
are  suited  for  the  settling  of  the  microbes.  The 
microbes  having  entered  the  tonsils  are  mostly 
destroyed  because  the  serum  kills  them.  The 
power  of  the  leucocytes  as  phagocytes  kills  them 
also.  Packard  claims  that  the  microbes  of  the 
acute  inflammator}'  rheumatism  are  streptococci 
weakened  through  the  action  of  the  tonsils,,  other- 
wise we  would  see  septic  diseases  oftener. 

"It  is  also  possible  that  the  microbes  enter  the 
system  through  the  blood  vessels."     (Grober.) 

"The  tonsils  seem  to  he  a  less  favorite  settling 
place  for  tubercle  bacilli  than  the  lymph  glands 
for  ice  find  scrofulous  glands  oftener  than  in- 
fection of  the  tonsils.  The  latter  see?n  to  sen'e 
as  an  entrance  portal  for  the  tubercle  bacilh." 
(Grober.) 

"The  more  radical  prophylaxis  would  be  to 
remove  all  tonsils  wliich  is  not  possible  without 
a  serious  operation,  and  even  then  many  equiva- 
lent parts  of  the  hmiphatic  throat  ring  would  be 
left  to  take  the  role  of  the  tonsils."     (Grober.) 

Another  question  would  be  whether  the  chron- 
ically diseased  tonsils  should  not  be  removed. 

"Many  authors  have  considered  diseased  tonsils 
as  more  liable  to  microbial  infection,  than  healthy 
ones.    If  that  «■  true,  it  is  not  proven.''  ( Grober. ) 

"Besides  the  medical  science  shows  that  the 
entrance  of  microbes  into  the  system  does  not 
always  produce  the  disease.  It  is  important  how 
strong  the  defensive  processes  of  the  body  are. 


PHYSIOLOGY    OF    THE    TONSIL  31 

Therefore,  infectious  diseases  are  mostly  consti- 
tutional diseases."     (Groher.) 

Has  the  faucial  tonsil  a  protective  mechanism 
to  protect  itself  against  infection?  Or,  does  this 
organ  serve  as  an  entrance  for  most  infections 
which  attack  the  general  system? 

Two  theories,  which  concern  the  physiological 
function  of  the  tonsils,  consider  chiefly  the  be- 
havior of  these  organs  towards  infections.  One 
theorj^  saj^s  that  the  tonsils  through  a  protective 
mechanism,  are  protected  against  infection — ^the 
theory  of  Brieger  and  Goerke. 

The  other  theory  says  that  the  tonsils  offer  no 
resistance  at  all  to  any  infection,  and  that  they 
sei'^'e  as  an  entrance  for  most  infections  which 
attack  the  organism. 

Brieger  shows  that  the  elements  of  the  adenoid 
tissue  are  not  leucocytes,  but  lymphocytes,  and 
that  to  these  latter  the  faculty  of  active  movement 
has  to  be  denied,  as  it  is  impossible,  Brieger  saj^s, 
that  "the  lymphocytes  enter  the  epithelium  on 
their  own  accord.  On  the  other  hand,  it  can  be 
proven  through  the  microscope  that  lymphocytes 
in  lesser  or  greater  degree  are  always  present  in 
the  epithelium  of  the  tonsils.  We  have  to  assume 
a  vehicle  which  carries  the  Ij^mphocytes  from  the 
adenoid  tissue;  this  vehicle,"  according  to 
Brieger,  "is  the  lymphatic  juice  which  fills  all 
crevices  between  the  tissue  and  which  gets  to  the 
surface  through  the  finest  canals.  The  cause  of 
the  movement  of  the  lymphatic  current  is  to  be 
found,"  according  to  Brieger  and  Goerke,  "in  a 
difference  of  pressure  in  the  afferent  lymphatic 
vessels  and  the  free  surface.     Increase  of  blood 


32  THE    TONSILS    AND    THE    VOICE 

pressure  increases  the  force  of  the  Ijrmphatic 
current.  Therefore,  if  the  blood  pressure  is  in- 
creased, the  lymphatic  juice  flows  stronger,  and 
quicker  through  the  epithelium,  and  carries  along 
a  larger  amount  of  lymphocytes  out  of  the 
adenoid  tissue." 

"The  stronger  the  lymphatic  current  flows 
through  the  epithelium,  the  larger  the  amount  of 
the  lymphocytes,  the  more  the  epithelium  will 
have  to  suffer."  But  Brieger  and  Goerke  do  not 
speak  of  a  destruction  of  the  epithelium  in  such 
a  case.  "But,"  according  to  these  authors,  "the 
continuity  of  the  epithelium  in  a  particularly 
strong  lymphatic  current  is  only  temporarily 
torn  by  the  strong  lymphatic  juice,  and  the  con- 
tinuit}^  is  re-established  immediately  as  soon  as 
the  intensity  of  the  lymphatic  current  is  dimin- 
ished." 

"Beside  the  theory  of  Brieger  and  Goerke,  that 
the  mechanism  of  the  tonsil  furnishes  a  protec- 
tive function,  there  is  another  protective  theory, 
that  of  Gullandj,  Kilmmel  and  JLindt.  Ghillund 
believes  that  the  tonsils  are  enabled  to  hinder 
germs  from  entering  deeper  into  their  substance 
and  thus  to  work  against  an  infection  of  the 
organism.  Gulland,  Kiimmel  and  Lindt  say  that 
the  tonsils  can  do  this  through  the  leucocytes 
which  possess  amaeboid  motion  as  well  as  the 
faculty  of  phagocytosis." 

"Gulland  states  that  as  soon  as  an  infectious 
germ  gets  into  the  depth  of  the  organ,  leucocytes 
devour  it  and  bring  it  back  to  the  surface." 

''Brieger  opposes  this  opinion,  showing  that  in 
the  tonsils  we  have  no  leucocytes,   but  mainly 


PHYSIOLOGY    OF    THE    TONSIL  33 

lymphocytes,  which  have  no  amaeboid  motion. 
Brieger  ascribed  the  power  of  the  tonsils  to  pro- 
tect themselves  against  infection  to  the  fact  that 
the  tonsils  have  a  continuous  lymphatic  current 
running  from  the  inside  to  the  outside  of  the 
organ.  This  current  works  against  the  entrance 
of  germs,  as  the  current  assisted  by  the  lym- 
phocytes washes  the  infectious  germs  away. 
Goerke  mentions  the  observation  of  Frdnkel  that 
children  with  hyperplastic  tonsils  are  less  easily 
affected  by  diphtheria  than  children  with  normal 
tonsils.  Goerke  thinks  that  the  bacteria  enter 
the  tonsils,  not  through  the  parenchyma  of  the 
tonsils,  but  through  the  other  mucous  membranes 
of  the  pharynx." 

"In  this  view,  the  researches  of  Menzer  are  of 
great  interest,  which  prove  that  just  in  that  dis- 
ease wherein  the  entrance  of  the  cause  through 
the  tonsil  was  considered  assured,  acute  articular 
rheumatism,  the  infection  took  its  way  through 
the  adjoining  tissue,  while  the  tonsils  only  be- 
came diseased  secondarily  from  the  inside. 
Goerke  claims  as  a  proof  for  his  theory  the  ex- 
planation of  Frdnkel,  given  for  angina  trau- 
matica, that  infectious  germs  in  the  nose  (after 
nasal  operations )  can  be  transported  via  the  lym- 
phatic vessels  to  the  tonsils  and  there  produce 
local  symptoms."  "We  see,"  Goerke  says,  "in  the 
Waldeyer  ring,  a  mechanism  in  action  which  in 
a  nearly  perfect  way  makes  the  tonsils  the  most 
important  protective  organ  in  the  body,  and  in 
this  sense  we  dare  speak  of  the  function  of  the 
tonsils." 

"Finally,  Goerke  calls  attention  to  the  fact  that 


34  THE    TONSILS   AND    THE    VOICE 

it  has  been  attempted  to  assist  the  active  physio- 
logic moment  in  the  tonsils,  by  means  intended  to 
accelerate  the  lymphatic  current,  that  is,  by  the 
suction  treatment  of  the  tonsils  in  different  in- 
flammatory processes  of  these  organs."  (Levin- 
stein.) 

'' S choenemann  says,  the  tonsils  very  rarely  be- 
come diseased  primarily,  but  almost  always  sec- 
ondarily. According  to  Schoenemann,  acute 
tonsillitis  has  to  be  considered  as  an  inflammation 
following  an  inflammation  of  the  neighboring 
tissue.  The  angina  fossularis,  according  to 
Schoenemann,  in  most  cases  is  caused  by  infec- 
tious germs  which  get  into  the  tonsils  via  the 
lymphatic  vessels  from  the  primarily  diseased 
mucous  membrane  of  the  nose  and  produce  a 
secondaiy  disease  of  the  tonsils.  Schoenemann 
mainly  blames  acute  coryza  as  being  the  origin 
of  angina,  assuming  that  many  infectious  germs 
present  on  the  affected  mucous  membrane  of  the 
nose  reach  the  tonsils  by  the  tymphatic  vessels 
and  produce  acute  inflammation  of  the  tonsils. 
A  proof  that  this  opinion  is  right  Schoenemann 
finds  in  the  fact  that  he  has  often  observed  that 
angina  (tonsillitis)  often  relapsing  did  not  occur 
again  after  the  nasal  mucous  membrane  had  been 
carefully  treated."     {Levinstein.) 

"The  immigration  of  leucocytes  from  the  in- 
side of  the  tonsil  through  the  epithelium,  as  dis- 
covered by  Stohr,  at  certain  places  is  so  strong 
that  it  is  difficult  to  find  the  epithelium.  By  this 
discovery  of  Stohr  the  idea  was  formed  that  the 
tonsils  represented  an  open  wound  of  our  body, 


PHYSIOLOGY    OF    THE    TONSIL  35 

SO  that  it  was  easy  for  micro-organisms  to  enter 
here  into  the  tissue." 

"On  the  ground  of  Brieger's  observations,  it  is 
generally  assumed  that  leucocytes  only  occur 
occasionally,  and  that  we  have  here  mainly  lym- 
phocytes." 

"The  lymphocytes,  as  you  know,  have  a  nu- 
cleus with  little  protoplasm,  while  the  leucocytes 
have  much  plasm  and  a  certain  amaeboid  move- 
ment." 

"The  lymphocytes  do  not  possess  this  motion, 
and  if  lymphocytes  pass  through  the  epithelium, 
we  have  to  assume  that  they  are  forced  through 
by  the  lymphatic  current  which  flows  from  the 
tissue  through  the  epithelium.  If  we  assume 
that  the  lymphatic  current  simply  takes  along 
the  Ij^mphocytes  like  logs  in  the  river,  we  have  to 
omit  the  idea  that  we  have  here  to  consider  an 
open  wound  hut  that  we  have  to  learn  to  consider 
it  a  protective  mechanism,  for  the  micro-organ- 
isms have  to  swim  against  the  current  and  meet 
cells  which  possess  a  certain  phagocytosis. 
Therefore,  the  idea  of  Brieger  that  the  tonsil  is  a 
protective  mechanism  has  to  be  generally  ac- 
cepted, and  we  cannot  talk  any  more  of  the  tonsil 
being  an  open  wound."     (Frdnkel.) 

''A  surface  lesion  must  always  be  supposed  to 
exist  when  a  living  germ  or  toxin  is  to  find  access. 
It  looks  rational  to  admit  that  where  there  is 
merely  a  surface  lesion,  though  ever  so  slight, 
there  may  be  an  invasion  into  the  tonsil.  When, 
however,  the  vessels  are  exposed  to  pressure  by 
newly  formed  cells  or  tissue,  there  is  no  invasion. 


36  THE    TONSILS    AND    THE    VOICE 

certainly  not  beyond  the  tonsil  itself,  no  gangli- 
onic swelling,  no  toxic  poisoning/'' 

"It  is  even  rational  to  believe  that  now  and 
then,  when  tonsils,  or  what  is  more  common,  a 
single  follicle,  becomes  inflamed,  the  very  venous 
obstruction  will  exert  the  bactericidal  influence  of 
the  stagnating  blood  serum/^ 

"Cell  infiltration  and  cicatricial  tissue  render 
absorption  less  possible.  Thus,  even  when  the 
surface  is  broken,  the  tonsil  must  not  be  con- 
sidered as  a  sure  port  of  entry  for  infectious 
germs.  Whenever  the  membrane  of  diphtheria 
is  limited  to  the  tonsil,  there  is  very  little,  or  no, 
glandular  swelling  in  the  neighborhood.  Dozens 
of  years  ago,  I  could  prove  that  diphtheria, 
when  limited  to  the  tonsils,  was  least  danger- 
ous. These  clinical  observations  have  stood  the 
test  of  time  and  must  be  reckoned  with." 
(Jacobi.) 

Thus  the  tonsils  are  proved  to  have  little  or  no 
absorptive  power  when  attacked  by  diphtheria. 

Schmiegelow  looks  upon  the  tonsil  as  a  part 
of  the  protecting  system,  which  is  represented  by 
all  the  lymphoid  tissue  to  be  found  everywhere 
in  the  mucous  membrane  of  the  pharynx  and 
naso-pharynx. 

Escat  believes  that  the  faucial  tonsil  has  the 
function  of  phagocytosis  as  studied  by  Metchni- 

Massei  believes  the  faucial  tonsils  have  a 
biologic  function  similar  to  the  lymphatic  tissue 
which  forms  the  so-called  Waldeyer  ring. 

"The  question,  what  object  have  the  lympho- 
cytes which  are  forced  through  the  epithelium? 


PHYSIOLOGY    OF    THE    TONSIL  37 

leads  to  the  opinion  that  it  must  be  a  certain 
safety  valve  action  which  prevents  the  continuous 
formation  of  lymphocytes  placing  the  lymphatic 
vessels  under  too  high  a  pressure.  The  epithe- 
lium itself  does  not  need  for  this  process  to  have 
large  channels.  If,  in  the  imniigt^ation  of  white 
corpuscles  through  the  walls  of  the  blood  vessels 
7iO  holes  are  made  in  those  vessels,  neither  is  it 
necessary  that  a  hole  he  formed  in  the  epithelium 
of  the  tonsil  when  lymphocytes  pass  through'' 
(Frdnkel.) 

"The  infection  from  the  outside  of  the  tonsil 
is  the  same  as  on  other  j)arts  of  the  body.  The 
infection  of  the  tonsil  from  the  blood  has  not  been 
sufficiently  considered,  at  least  I  do  not  find  it 
often  enough  in  the  ideas  of  physicians.  If  one 
injects  into  the  veins  of  rabbits  colored  particles 
we  can  show  them  in  the  tonsils.  After  certain 
operations  in  the  nose,  in  many  cases  two  days 
later,  angina  (tonsillitis)  occurs." 

"If  we  try  to  understand  these  observations 
we  must  assume  that  microbes  from  the  nose 
have  entered  the  tonsils,  that  the  operation  in  the 
nose  has  opened  the  door  through  which  the 
micro-organisms  could  get  into  the  lymjihatic 
circulation  to  affect  the  tonsils.  If  you  inject 
Chinese  Tusche  (black  color)  under  the  lining 
of  the  nose  of  rabbits,  dogs  and  hogs,  you  can 
show  in  a  short  while  these  color  particles  in  the 
tonsils.  We  can  think  now  that  angina  is  caused 
from  distant  organs,  especially  from  the  nose, 
and  perhaps  the  preparatory  coryza  which  we 
often  find  in  angina  is  because  of  the  angina  it- 
self.    This  idea  affords  for  infectious  diseases 


38  THE    TONSILS    AND    THE    VOICE 

another  consideration.  We  can  now  not  think 
any  7nore  that  this  is  caused  by  microbes  advan- 
cing through  the  mouth/' 

"We  observe  angina  in  many  secondary 
diseases.  One  of  the  best  known  is  the  periton- 
sillar abscess.  The  micro-organisms  invade  the 
tissue  surrounding  the  tonsils." 

"It  is  important  to  understand  that  the  tonsils 
can  be  infected  from  the  blood  and  the  lymjjhatic 
vessels  with  tuberculosis,  just  as  from  the  surface, 
but  I  believe  that  most  infections  which  we  find 
in  the  tonsils  are  secondary,  mostly  from  the  nose. 
These  cases  belong  mostly  to  the  latent  tuber- 
culosis. Children  are  comparatively  healthy." 
(Frdnkel.) 

"The  protective  theory  of  Brieger  and  Goerke 
would  seem  to  have  a  great  deal  of  probability 
if  it  were  proven  absolutely  that  the  lymphocytes 
have  not  the  power  of  locomotion.  So  far  this 
does  not  seem  to  have  been  proven.  The  current 
has  not  been  seen  by  anybody  or  proved  by  any- 
body. In  the  current  theory  at  this  time  we  can 
see  nothing  but  an  erudite  hypothesis."  (Levin- 
stein. ) 

"There  is  no  doubt  that  a  great  number  of  the 
ordinary  anginas  have  to  be  co7isidered  as  a  pri- 
mary acute  infection  of  the  tonsils.  Of  course, 
the  tonsils  become  diseased  secondarily,  like  the 
one  we  see  in  secondary  lues  and  condylomata. 
I  have  also  to  mention  the  well-known  angina, 
following  endonasal  operations." 

"In  these  diseases,  called  by  Frdnkel  angina 
traumatica,    the   infection    occurs    in   this    way, 


PHYSIOLOGY    OF    THE    TONSIL  39 

namely,  that  the  germs  are  transported  from  the 
nose  to  the  tonsils  and  produce  local  symptoms." 
(Levinstein.) 

''Btieger  assumes  a  current  which  permanently 
flows  through  the  whole  organ  from  the  inside  to 
the  outside  and  which  carries  along  more  or  less 
lymphocytes.  If  this  current  is  very  strong  the 
number  of  lymphocytes  is  larger  and  the  alter- 
ation of  the  epithelium  more  pronounced." 

"The  insult  to  the  epithelium  by  the  current 
loaded  with  lymphocytes  does  not  produce  the 
effect  that  microbes  get  more  easily  into  the 
tissues,  as  the  intervals  in  the  epithelium  are  con- 
stantly filled  with  the  current  and  the  possible 
lesions  to  the  epithelium  are  never  lasting  defects 
but  disappear  as  soon  as  the  intensity  of  the 
current  is  diminished.  But  nobody  has  seen  this 
current  and  that  the  lesion  of  the  epithelium  is 
only  transitory  has  not  been  proven.'" 

"We  are  not  entitled  to  see  in  the  histologic 
picture  of  the  tonsil  a  proof  for  the  existence  of 
the  current  flowing  from  the  inside  to  the  outside 
of  the  organ." 

"There  is  not  a  single  experiment  which  proves 
that  the  tonsils  possess  the  faculty  to  resist  the 
entrance  of  microbes  with  greater  success  than 
the  mucous  membrane  of  the  pharynx  is  able  to 
do.  Therefore,  we  must  say  that  experimeiits 
so  far  do  not  prove  a  distinctive  protective 
mechanism  of  the  tonsils,  although  they  do  not 
oppose  such  a  possibility."     (Levinstein.) 

"There  seems  to  be  no  doubt  that  the  tonsils 
are  very  often  diseased  primarily,  and  that  their 
frequent  secondary  infection  does  seem  to  be  ap- 


40  THE    TONSILS    AND    THE    VOICE 

provedj  and  that  they  are  particularly  "well  pro- 
tected against  infections''     (Levinstein.) 

"The  infection  theory  of  the  tonsil  considers 
that  most  diseases  of  the  human  being  are  pro- 
duced by  a  primary  infection  of  the  tonsils, 
JVinslow  claims  that  the  tonsils  are  a  menace  to 
the  organism.  I  rather  believe  that  the  infection 
theory  is  too  extreme,  and  I  beheve  that  the  ton- 
sils offer  less  resistance  to  infectious  germs  than 
the  other  lymphatic  organs  of  the  throat.  But  if 
the  tonsil  offers  less  resistance  to  infections  than 
its  neighborhood  we  are  not  yet  entitled  to  talk  of 
a  danger  to  the  organism.  And  if  Bosworth, 
Hendelssohn,  and  others,  come  to  the  conclusion 
that  the  tonsils  are  a  constant  danger  and  should 
in  all  human  beings  be  totally  eradicated,  I  can- 
not come  to  the  same  conclusion,  for  if  I  know  of 
an  organ  that  becomes  easily  infected,  this  organ 
should  not  be  destroyed,  but  we  should  try  to  per- 
fect it  as  much  as  possible  against  the  danger  of 
infection,  which  in  the  tonsils  is  not  so  difficult  to 
do:' 

"We  want  to  make  the  organ  more  resistible. 
We  want  to  cure  and  not  destroy.  Total  and 
lasting  destruction  is,  as  Goerke  has  proved,  abso- 
lutely impossible.  The  tonsils  as  organs  easily 
infected  have  to  be  particularly  protected  against 
the  possibility  of  infection."     {Levinstein.) 

Harrison  Allen  believed  that  a  large  per  cent 
of  children  suff ermg  from  hyperplasy  of  the  f au- 
cial  tonsil,  who  mentally  and  bodily  remain  be- 
hind normal  children,  has  to  be  considered  as  sub- 
ject to  an  inner  secretion  of  the  hyperplastic  or- 


PHYSIOLOGY   OF   THE    TONSIL  41 

gan  which  produced  a  damaging  effect  on  the  or- 
ganism. 

Escat  "beheves  that  the  faucial  tonsils  have  not 
for  their  only  function  that  of  phagocytosis 
studied  by  Metch^iikoff,  but  also  a  physiological 
and  biological  function,  due  to  an  internal  secre- 
tion. He  believes,  in  accord  with  Allen,  that  the 
tonsils  secrete  a  principle  the  nature  of  which  it 
has  been  unable  to  determine,  but  which  should  be 
useful  in  the  development  and  to  the  growth  of 
the  subject,  and  probably  to  the  growth  of  the 
skeleton.^' 

Masini  "believes  that  the  tonsil  has  an  inner 
secretion  similar  to  the  suprarenal  and  other 
glands. 

"He  injected  many  animals  with  the  extract 
of  tonsils,  and  produced  an  increase  in  the  arte- 
rial pressure.  Scheier  made  analogous  experi- 
ments by  which  he  produced  a  decrease  in  arterial 
pressure.  Pugnat  repeated  these  experiments, 
but  could  not  produce  either  increase  or  decrease 
in  the  arterial  pressure.  Masini,  Scheier  and 
Pugnat  had  all  three  different  results,  and  so 
proved  nothing." 

The  haematopoietic  theory  of  Harrison  Allen, 
Kayser,  Pluder  and  Schoenemann  considers  the 
function  of  the  tonsil  to  be  that  of  producing  new 
colorless  blood  corpuscles.  As  we  find  in  normal 
tonsils  always,  follicles  with  cell  producing  cen- 
ters, we  can  claim  with  assurity  that  in  the  normal 
tonsil  new  lymphocytes  are  produced,  and  that  in 
the  hypertrophied  tonsil  the  number  of  newly 
formed  lymphocytes  is  always  considerably  larger 


42  THE    TOXSILS    AND    THE    VOICE 

than  in  the  normal  tonsil.  In  the  atrophic  tonsil 
new  lymphocytes  are  not  formed. 

"The  question  as  to  what  becomes  of  these 
newly-formed  Ij'^mphocytes  is  not  decided.  That 
they  are  put  into  the  circulation  has  to  be  con- 
sidered doubtful,  so  long  as  it  has  not  been  proved 
that  the  vasa  efferentia  of  the  tonsil  contain  a 
larger  amount  of  lymphocytes  than  the  afferen- 
tia.  So  far  this  has  not  been  proved,  and  it  will 
be  very  difficult  to  prove  because  it  is  impossible 
to  say,  from  the  histologic  picture,  which  is  the 
afferentia  and  which  the  efferentia."  (Levin- 
stein. ) 

"Not  a  small  number  of  the  lymphocytes  con- 
stantly leave  the  tonsil,  by  wandering  through 
the  epithelium.  I  have  proved  that  a  consider- 
ably^ larger  number  leave  the  hyperplastic  tonsil 
than  the  normal  organ.  What  we  know  is  sim- 
ply the  fact  that  new  lymphocytes  are  formed  in 
the  normal  tonsils.  What  becomes  of  them  we 
do  not  know."     {Levinstein.) 

''I  cannot  approve  of  eradicating  the  tonsils. 
If  one  tells  me  that  the  tonsils  have  no  distinct 
function,  and  on  the  other  hand,  become  easily 
diseased,  and  therefore  not  the  slightest  cause 
exists  to  save  these  organs,  I  mu^t  say  that  it  is 
not  impossible  that  the  tonsils  have  a  distinct 
physiological  function,  only  thus  far  we  have  no 
proof  of  it.  And  then  even  if  we  were  sure  that 
the  tonsils  had  no  distinct  function,  I  would  not 
give  up  my  conservative  standpoint,  for  if  an 
organ  of  our  body  and  even  one  which  is  not 
necessary  for  the  existence  of  the  organism  should 
prove  less  resistible  than  other  organs,  this  air- 


PHYSIOLOGY    OF    THE    TONSIL  43 

cumstance  does  not  at  all  entitle  us  to  destroy  this 
organ.''     (Levinstein.) 

In  concluding  his  scholarly  review  and  master- 
ly criticism  of  the  many  hypotheses  regarding  the 
f aucial  tonsil,  Von  Levinstein  says :  "No  theoiy 
considering  the  physiology  of  the  tonsils  can  be 
approved  of,  A  proof  that  the  tonsils  fill  a 
peculiar  function  important  for  the  organism 
has  not  been  given  by  anybody.  Whether  they 
have  such  a  function  cannot  yet  be  decided.  It 
has  not  been  settled  whether  the  tonsils  have  a 
value  or  not  for  the  organism." 

The  eocistence  of  the  lymphatic  current  from 
the  inside  of  the  follicle  through  the  epithelium 
to  its  surface  has  not  been  seen  by  anybody. 
Brieger  and  Frdnkel  assume  that  it  exists. 

Stohr's  idea  that  the  epithelium  of  the  tonsil 
represents  an  open  wound  has  been  well  com- 
batted  by  Frdnkel  and  by  Jacohi. 

The  elaborate  and  conscientious  research  works 
of  Retterer,  Labhe  and  Sirugue  and  Stohr,  and 
the  original  investigations  of  Brieger,  Goerke, 
Gulland,  Lindt,  Kilmmel,  Metchnikoff,  Bos- 
worth,  Hendelssohn,  Leocer,  Menzer,  Allen, 
Kayser^  Pluder,  Scheier,  Masini,  Hodenpyl, 
Pugnat,  Wood,  Fooc,  Scanes  Spicer,  Schoene- 
mann,  Merkel  Frdnkel,  Levinstein,  Magouhy, 
Hicguet,  Broeckaert,  Von  Lendrt,  Groher,  Poli, 
Frederici,  Most,  Goodale  and  Hartz  have  not 
proved  that  the  f aucial  tonsil  has  any  physiolog- 
ical function. 

(1)  There  is  no  proof  of  a  lymphatic  current 
running  from  the  inside  of  the  tonsil  to  the  sur- 
face of  its  epithelium,  as  suggested  by  Brieger. 


44  THE    TONSILS    AND    THE    VOICE 

(2)  There  is  no  absolute  proof  that  the  lym- 
phocytes have  not  amaeboid  movement^  as 
suggested  by  Brieger. 

(3)  There  is  no  proof  that  the  tonsil  possess- 
es the  power  of  phagocytosis  as  claimed  by 
Gulland. 

(4)  There  is  no  proof  that  the  tonsils  have  a 
haematopoietic  function,  as  claimed  by  Allen. 

(5)  There  is  no  jjroof  that  the  tonsils  have  an 
intetmal  secretion,  as  claimed  hy  Masini. 

(6)  There  is  no  proof  that  the  epithelium  of 
the  tonsil  ever  presents  an  open  wound,  as 
stated  bjr  Stohr. 

(7)  There  is  no  proof  that  the  tonsil  is  a  port 
of  entry  for  infectious  germs — no  proof  that  it 
has  any  absorbent  power. 

(8)  There  is  no  proof  as  to  the  existence  of 
afferent  and  efferent  lyjnphatic  ducts  leading  to 
or  from  the  surface,  into  the  body  of  the  tonsil. 

ON  THE  CONTRARY, 

(1)  There  is  the  proof  of  Hodenpyl  that  he 
could  not  force  absorption  by  the  tonsil  of  fats, 
liquids  or  powders. 

(2)  There  is  the  proof  of  Grober,  who  demon- 
strated the  comparative  absence  of  a  direct  com- 
munication of  the  tonsil  with  the  rest  of  the  body 
through  the  surrounding  fibrous  capsule.  His 
injections  of  the  tonsil,  under  pressure,  accumu- 
lated in  large  quantities  under  the  capsule. 

(3)  There  is  the  proof  of  Jacobi,  that  the 
tonsil  does  not  absorb  the  toxin  of  diphtheria. 

(4)  There  is  the  proof  of  Von  Levinstein,  that 
the  groups  of  acinous  mucous  glands  in  the  well- 


PHYSIOLOGY    OF    THE    TONSIL  45 

known  figure  by  JLuschha,  of  the  fauclal  tonsil 
does  not  belong  to  the  faucial  tonsil  proper,  but 
to  its  neighborhood. 

(5)  There  is  the  proof  of  Frederici  and 
Goerke  that  the  tonsils  are  infected  via  the  blood. 
If  colored  particles  are  injected  into  the  veins, 
they  appear  in  the  tonsils. 

(6)  There  is  the  proof  of  Von  Lendrt,  of  the 
statement  of  Frdnkel,  that  micro-organisms  ab- 
sorbed from  a  wound  in  the  nose  are  carried  via 
the  lymphatic  circulation  into  the  tonsil. 

"Science  owes  a  great  deal  to  the  reasoning 
power  of  the  thinker,  and  to  the  acumen  of  the 
guesser,  but  both  are  alike  futile  until  facts  are  ac- 
curately determined."     (Halliburton.) 

IF  THE  FAUCIAL  TONSIL 

( 1 )  Does  not  possess  a  protective  mechanism ; 
(2)  does  not  have  a  phagocytic  function;  (3) 
does  not  have  a  haematopoietic  function;  (4) 
does  not  have  an  internal  secretion;  (5)  does  not 
absorb  infections,  then 

WHAT  DOES  IT  DO,  IF  ANYTHING? 
HAS  IT  A  RIGHT  TO  EXIST?  or, 
IS  IT  AN  ATA  VISM? 

Do  the  theories  of  Briefer,  Gulland,  Allen, 
Masini,  and  Stohr,  cover  the  entire  range  of  in- 
vestigation that  pertains  to  the  usefulness  of  the 
faucial  tonsil?  Are  the  unproved  hypotheses  of 
these  learned  searchers  to  he  accepted  as  a  finality, 
and  their  results  permitted  to  hinder  other  re- 
search? Surely  not.  Betterer,  Lahhe,  Sirugue, 
JStohr,    Gulland,   Allen,   Masini,    Von   Lendrt, 


46  THE    TONSILS    AND    THE    VOICE 

Broechaert,  Poli  and  Von  Levinstein,  may  be  con- 
sidered to  have  gathered  all  possible  data  within 
the  range  of  their  investigations;  hut  there  are 
other  fields  open  to  investigation,  which  may 
elucidate  the  functions  of  the  faucial  tonsil.  Not 
alone  the  biologist,  the  physiological  chemist,  the 
pathologist,  the  bacteriologist,  the  anatomist,  and 
the  surgeon,  are  to  be  consulted  in  regard  to  the 
function  of  the  faucial  tonsil,  but  considering 
these  in  one  group,  as  that  of  medical  men,  there 
are  three  other  groups,  that  may  contribute  to 
Our  knowledge,  namely;  voice  mechanicians 
(physicists,  phoneticians,  and  acousticians), 
voice  trainers,  and  voice  users. 

In  consideration  of  the  sterility  of  biological 
and  physiologico-chemical  laboratory  research, 
pertaining  to  the  function  of  the  faucial  tonsil,  I 
question  the  wisdom  of  classifjdng  this  organ  as 
a  component  part  of  the  Waldeyer  lymphatic 
ring,  BECAUSE, 

(1)  It  lacks  the  most  ordinary  and  essential 
features  of  the  ly7nphatic  structures,  and  of  the 
tonsils  that  compose  the  ring. 

(2)  It  possesses  important  mechanical,  acous- 
tic and  phonetic  functions  which  are  not  possessed 
by  any  other  body  of  the  ring. 

The  mechanical  functions  and  mechanical  af- 
fections of  the  faucial  tonsil  are  nowhere  men- 
tioned in  medical  textbooks.  But  they  receive 
attention  in  the  literature  of  the  voice  profession. 

Observing  carefully  the  remarkable  anatomi- 
cal situation  of  the  faucial  tonsil  and  its  sus- 
pended position  in  the  very  center  of  a  framework 
of  curious,  active  and  important  muscles,  it  be- 


PHYSIOLOGY    OF    THE    TONSIL  47 

[ 

comes  pertinent  to  ask  whether  it  has  mechanical 
functions,  and  whether  it  is  subject  to  mechani- 
cal diseases  ? 

In  many  respects  the  faucial  tonsils  resemble 
and  are  as  soft  as  the  cartilages  of  the  larynx 
and  trachea.  They  impart  firmness  to  the 
pharyngeal  walls.  They  evidently  serve  a  pur- 
pose that  hard,  unyielding,  osseous  formations  in 
their  situation  would  not  serve.  They  are  mobile 
and  compressible. 

The  position  of  the  tonsils  changes  rapidly  and 
with  great  facility,  thereby  adding  vastly  greater 
measure  to  their  mechanical  usefulness. 

Their  consistence,  shape,  size,  position,  pres- 
ence or  absence  give  structural  variation  to  the 
resonance  cavities,  and  create,  as  well  as  deter- 
mine, differences  in  individual  timbres  of  the 
voice. 

They  play  a  role  in  tone  formation;  and  they 
must  be  considered. 

The  muscles  of  the  fauces  attract  attention 
when  at  rest,  by  the  remarkable  bowed  or  arched 
appearance  which  they  assume.  They  straighten 
when  they  contract.  Therefore,  I  consider  it 
most  reasonable  to  believe  that  on  account  of  its 
position  between  these  bowed  muscles,  the  faucial 
tonsil  acts  as  a  fulcrum  over  which  these  muscles 
play. 

John  Howard,  ''Physiology  of  Artistic  Sing- 
ing/" states : 

"It  is  true  that  a  muscle's  contraction  consists 
in  an  effort  to  shorten  itself.  If  the  muscle,  be- 
fore contraction,  has  the  form  of  a  curve,  then  its 
contracting  effort  will  shorten  it  to  a  straight' 


48  THE    TONSILS    AND    THE    VOICE 

form,  before  it  pulls  upon  its  points  of  attach- 
ment." 

"If  the  two  bodies  to  which  the  ends  of  the 
muscle  are  fastened  are  by  some  other  force 
pulled  farther  apart,  with  a  power  greater  than 
the  contracting  force  of  the  muscle,  then  the 
muscle  may  still  contract,  or  put  forth  its  effort 
to  shorten  itself,  although  at  the  same  time  it  is 
being  actually  lengthened.  In  this  case,  which  is 
constantly  occurring  in  vocal  performances,  the 
muscle  actually  loses  in  thickness,  and  becomes 
more  slender  during  its  own  contraction." 

"If  a  muscle  embraces  in  its  curve  any  yielding 
part,  it  will,  in  its  effort  to  draw  itself  straight, 
push  this  yielding  part  out  of  its  straightening 
way,  thus  exerting  a  lateral  or  sidewise  force,  as 
well  as  that  longitudinal  or  lengthwise  force 
which  draws  its  points  of  attachment  nearer  to- 
gether." 

"Even  if  the  embraced  or  curved-about  part  is 
too  firm  lo  be  actually  displaced  by  the  sidewise 
push  of  a  curved  muscle,  yet  this  part  will  be 
pushed  upon  and  made  more  solid  or  dense.  In 
this  case  the  muscle  will  pull  more  or  less  strongly 
the  more  or  less  firm  and  unyielding  the  enclosed 
part  may  be." 

"Whenever  an  arched  faucial  muscle  straight- 
ens, the  tonsil  is  either  pulled  or  pushed.  It  is 
drawn  inward  toward  the  median  line  of  the 
mouth,  by  the  palato-glossus  muscle,  which 
curves  outward  while  at  rest.  The  palato- 
pharyngeus  muscle,  also,  upon  contracting  and 
straightening,  draws  the  tonsil  inwardo  These 
palate-tongue   muscles   cannot  have   put   forth 


PHYSIOLOGY    OF    THE    TONSIL  49 

their  tongue  supporting  effort,  if  the  tonsil  re- 
mains unmoved  instead  of  moving  inward.  The 
tonsil  is  pressed  toward  the  median  line  by  the 
superior  constrictor  of  the  phar3rnx." 

It  is  also  pressed  downward  and  inward  be- 
tween the  pillars  of  the  fauces  in  the  act  of  swal- 
lowing. 

"It  has  been  shown  that  the  inward  straighten- 
ing of  the  outward-curving  part  of  the  supe- 
rior constrictor,  which  extends  from  the  side 
of  the  tongue  to  the  middle  of  the  rear  wall  of 
the  pharynx,  was  one  of  the  three  agents  which 
could  hold  up  the  tongue.  If  the  internal  ptery- 
goid muscle,  just  outside,  is  relaxed,  it  will  be  so 
loose  that  it  will  readily  follow  the  inward- 
moving  curve  of  the  glosso-pharyngeus  muscle 
and  the  higher  division  of  the  superior  constric- 
tor, outside  of  which  it  runs.  But  if  it  is  held 
stiff  by  contraction,  it  will  not  yield,  and  may 
prevent  the  free  inward  straightening  of  the 
curve,  thus  interfering  with  the  vocal  action  of 
the  tongue,  supporting  the  glosso-pharyngeus 
(tongue  part  of  the  superior  constrictor) ." 

"Possible  proof  of  this  interference  is  afforded 
by  touching  one  of  the  tonsils  and  then  trying  to 
bring  it  inward  at  first  with,  and  then  without, 
jaw  setting  or  stiffening,  when  it  will  be  apparent 
that  the  inward  movement  of  the  palato-larynx 
muscle  is  in  some  way  (probably  in  this)  checked 
to  some  extent  during  the  jaw  stiffening;  for 
upon  relaxing  the  jaw  effort,  the  tonsils  come 
nearer  together  with  less  vocal  effort." 

"There  can  be  no  doubt  that  the  palato-glossi 
muscles  raise  the  tongue  after  having  straight- 
5 


50  THE    TONSILS    AND    THE    VOICE 

ened  themselves.  It  is  also  clear  that  they  can 
draw  the  soft  palate  downward." 

"Push  the  end  of  a  finger  backward  in  the 
mouth  over  the  lower  teeth,  till  you  press  lightly 
against  a  smooth,  lumpy  mass,  the  tonsil;  now 
sing  a  tone,  and  know  that  you  are  so  far  right, 
if  this  fleshy  mass  is  drawn  inward  toward  the 
middle  of  the  mouth ;  wrong  if  it  does  not  move 
inward." 

"This  mass,  the  tonsil,  is  drawn  inward  by  the 
palato-glossus  muscle  which  here  curves  outward 
while  relaxed,  and  necessarily  straightens  inward 
drawing  inward  the  tonsil." 

"These  palate-tongue  muscles  cannot,  then,  be 
putting  forth  their  tongue-supporting  effort  if 
the  tonsil  remains  unmoved." 

"The  tonsil  may  also  be  drawn  inward  by  the 
palato-pharyngei  muscles." 

There  is  an  infinitely  varied  and  ceaseless  play 
upon  the  faucial  tonsils  by  the  muscles  of  the 
fauces,  pharynx,  larynoc,  mouth  and  jaw. 

In  this  connection,  mark  well — that  the  fibrous 
capsule  of  the  faucial  tonsil  is  the  point  of  inser- 
tion of  muscular  fibres  derived  from  the  superior 
constrictor  muscle  of  the  pharynx. 

Why  are  muscular  fibres  from  the  superior 
constrictor  inserted  into  the  tonsil?  Is  the  inser- 
tion of  these  fibres  in  a  soft  and  movable  body 
like  the  tonsil,  designed  to  give  freer  action,  and 
to  facilitate  some  special  play  upon  the  part  of 
this  muscle  ?  Does  the  yielding  tonsil  serve  some 
function  to  the  superior  constrictor,  which  inser- 
tion in  a  bone  would  not  ?  And  has  the  action  of 
the  superior  constrictor  led  to  the  development  of 


PHYSIOLOGY    OF    THE    TONSIL  51 

the  tonsil  with  its  strong  aponeurotic   sheath? 
These  questions  remain  to  be  solved. 

The  faucial  tonsil  is  a  fulcrum  for  the  muscles 
of  the  pharynx.  It  is  also  a  compressible  and  a 
movable  fulcrum. 

The  faucial  tonsil  is  a  muscular  compensator, 
which  supj)lies  compensation  by  change  in  its  po- 
sition, and  by  change  in  its  pressure,  and  by 
change  in  its  shape  when  compressed. 

Also,  by  its  presence,  it  fills  a  cavity,  which,  if 
unoccupied,  would  cripple  compensation.  It's  an 
idler. 

Acting  as  a  fulcrum,  as  a  compensator,  as  an 
idler,  and  by  change  in  its  shape  when  com- 
pressed, the  faucial  tonsil  is  an  important  factor 
in  assisting  the  muscles  and  in  the  shaping  and 
re-shaping  of  the  walls  of  the  pharynx. 

The  normal  tonsil  is  a  normal  part  of  the 
mechanism  that  engages  in  voice  production,  and 
the  removal  of  the  tonsil  will  derange  and  dam- 
age the  mechanism. 

It  is  stated  by  Von  Chiari  that  "in  elder  pro- 
fessional singers,  in  whom  the  tonsils  are  enlarged 
to  a  great  degree,  and  press  apart  the  faucial 
arches,  extending  them  very  much  in  the  course 
of  years,  the  tonsils  act  as  a  prop  in  supporting 
the  soft  palate ;  the  muscles  of  the  faucial  arches 
become  insufficient,  while  the  arches  remain  tense, 
being  supported  by  the  big  tonsils.  If  these  ton- 
sils are  removed  to  the  bottom  of  the  sinus  tonsil- 
laris, the  faucial  arches  will  lose  their  support, 
and  the  whole  back  part  of  the  roof  of  the  mouth 
will  sag  down,  affecting  the  voice  permanently." 

Howard    states:    "The    soft    palate   may    be 


52  THE    TONSILS    AND    THE    VOICE 

roughlj"  compared  to  a  tongue  which  has  its  root 
at  the  rear  edge  of  the  hard  palate,  and  after  ex- 
tending backward  turns  its  tip  downward,  leav- 
ing a  small  space  unfilled  between  its  downward 
curved  part  and  the  spine,  or  rear  wall  of  the 
pharynx." 

"On  both  sides  of  it,  the  four  pairs  of  muscles 
which  really  constitute  nearly  its  whole  substance, 
start  out ;  two  stretching  upward  and  two  down- 
ward. The  two  downward  ones  are  the  palato- 
pharyngei  and  the  palato-glossi.  The  two  up- 
ward inclined  pairs  must  be  examined  in  search 
of  the  forces  which  can  hold  up  this  unsupported 
tongue-like  palate  against  the  do^vn-pulling 
muscles  just  mentioned." 

"For,  if  tliis  support  fail,  the  whole  chain  of 
muscles,  from  palate  to  breast  bone,  will  be,  in  a 
sense,  let  down,  enfeebled  bj^  being  shortened, 
and  withheld  instinctively  from  even  making  the 
effort  still  possible,  from  fear  of  midue  straining 
upon  a  tender,  unsupported  fleshy  mass." 

It  is  impossible  to  conceive  of  any  calamity 
that  would,  with  more  certainty,  permanently  de- 
stroj^  the  singing  voice. 

Howard  says:  "To  the  anatomist  or  the  physi- 
ologist, the  surgeon  or  the  general  practitioner, 
no  smallest  j^art  of  the  whole  throat  can  seem  un- 
important. Baron  Cuvier  said  that  'not  only  the 
muscles  of  the  larynx  serve  to  modulate  the  voice, 
but  also  those  of  the  hyoid  bone,  tongue  and  veil 
of  the  palate,  without  which  one  could  not  attain 
the  degree  of  modulation  necessary  for  singing.'  " 

I  have  presented  the  foregoing  data  to  show 
the  mechanical  relationship  and  influence  of  the 


PHYSIOLOGY   OF    THE   TONSIL  53 

action  of  certain  muscles  upon  the  faucial  tonsil, 
and  to  form  a  groundwork  upon  which  I  will 
place  evidence  in  support  of  the  following  state- 
ments : 

( 1 )  The  faucial  tonsil  plays  an  important  role 
in  the  mechanism  of  voice  production. 

(2)  The  mis-use  of  the  voice  by  an  incorrect 
method  in  singing  or  speaking  acts  in  a  mechan- 
ical way  in  causing  enlargement,  or  disease,  of 
the  tonsil. 

(3)  Tonsils  enlarged,  or  diseased,  through  a 
wrong  method  of  voice  production,  may  he  cured 
by  the  substitution  of  a  correct  method. 

(4)  Tonsils  that  are  swollen,  tender  and  pain- 
ful, caused  by  the  mis-use  of  the  voice,  will,  in 
turn,  by  their  abnormal  condition,  hinder  the 
proper  action  of  the  voice  mechanism,  and  this 
hindrance  will  be  relieved  by  proper  use  of  the 
voice. 

(5)  Removal  of  the  normal  faucial  tonsil  in- 
terferes with  the  mechanism  of  the  voice. 

(6)  The  presence  of  the  faucial  tonsil  being 
essential  as  a  factor  in  voice  mechanism,  its  ab- 
sence necessarily  interferes  with  the  perfect  ac- 
tion of  the  mechanism  and  is  necessarily  inimical 
to  the  formation  of  a  good  singing,  or  public- 
speaking,  tone. 

(7)  The  mere  absence  of  the  normal  faucial 
tonsil  impairs  and  weakens — and  the  presence  of 
adhesions,  scars,  and  contractions  incidental  to 
its  removal,  interferes  with — the  mechanism  of 
the  voice. 


54  THE    TONSILS    AND    THE    VOICE 

( 1 )  The  faucial  tonsil  plays  an  important  role 
in  the  mechanism  of  voice  production. 

The  faucial  tonsils  assist  in  regulating  the  ac- 
tion of  the  faucial  pillars.  As  muscular  com- 
pensators, they  undoubtedly  act  upon  and  change, 
direct  or  interfere  with,  the  course  of  the  vibra- 
tions of  sound.  They  contribute  to  altering  the 
timbre  of  the  voice.  They  help  to  sustain  the  tone. 

Alewander  Graham  Bell  says:  "Every  change 
in  the  shape  of  the  passage  way,  through  which 
the  voice  is  passed,  occasions  a  corresponding 
change  in  the  quality  of  the  voice." 

Manuel  Garcia  says:  "Every  sound  of  the 
voice  may  assume  an  infinite  variety  of  shades 
apart  from  intensity.  Each  of  these  is  a  timbre. 
The  path  of  the  sound  being  formed  of  elastic 
and  movable  parts  varies  the  dimensions  and 
forms  in  endless  ways,  and  every  modification, 
even  the  slightest,  has  a  corresponding  and  defi- 
nite influence  on  the  voice." 

Van  Baggen  says:  "The  faucial  tonsils  play 
an  important  role  in  phonetics.  Their  situation 
in  the  mouth  at  a  place  where  the  voice  receives 
an  essential  part  of  its  specific  qualities  allows  us 
to  admit  this  assertion.  The  muscles  of  the  an- 
terior and  posterior  fauces  between  which  the 
tonsils  rest  are  in  constant  movement  when  speak- 
ing or  singing.  Their  action,  combined  with  the 
movements  of  the  muscles  of  the  soft  palate, 
changes  the  shape  of  the  voice  passage  at  the  back 
of  the  mouth  when  we  are  forming  the  different 
vocals  or  producing  tones  of  different  pitch.  The 
position  of  the  tonsils,  situated  as  they  are 
between  the  fauces,  are  of  great  importance  with 


PHYSIOLOGY    OF    THE    TONSIL  55 

regard  to  the  exactitude  and  perfectness  of  these 
movements." 

"Also  for  the  resonance  the  tonsils  are  of  great 
interest  for  the  voice.  With  their  spongy  tissue 
they  can  be  compared  to  the  felt  in  the  piano 
which  softens  the  tone  and  regulates  the  reson- 
ance. The  quantity  and  quality  of  the  accessory 
tones  depend  on  the  shape  of  the  resonance 
cavity.  By  modifying  the  shape  of  the  resonance 
cavities,  tones  of  different  qualities  and  in  differ- 
ent quantities  are  put  in  co-vibration  by  the 
vibration  of  the  keynote.  The  mis-use  of  the  ac- 
cessory tones  is  frequently  the  cause  of  a  husky 
and  impure  voice." 

Moure:  "From  a  phonetic  point  of  view,  the 
normal  role  of  the  tonsils  must  evidently  be  to 
prevent  in  a  certain  measure  the  nasality  of  tone 
by  maintaining  the  pillars  in  the  midst  of  which 
they  are  placed." 

Lamperti:  "The  tonsils  are  most  necessary  for 
modulation  in  singing;  without  them  it  is  very 
difficult,  sometimes  impossible,  for  the  voice  to 
modulate.  They  assist  in  expanding  and  with- 
drawing the  tones — in  crescendo  and  diminuendo. 
The  tonsil  is  as  necessary  for  the  modulation  of 
the  voice  as  the  nostril  is  to  breathing." 

Mme.  Luisa  Cajj'piani:  "The  tonsils  are  neces- 
sary to  the  acoustics  of  the  voice.  They  support 
the  tone  in  crescendo  and  decrescendo.  Without 
tonsils,  you  cannot  always  strike,  and  you  never 
can  sustain  the  singing  tone ;  it  fades  away.  With 
the  tonsils  in  the  natural  position,  of  the  head,  it 
is  much  easier  to  bring  the  tones  into  the  sound- 


56  THE   TONSILS   AND   THE   VOICE 

Ing  board,  the  nasal  bridge  where  the  voice  be- 
comes mellow  and  sonorous." 

Escat:  "The  pharynx  in  its  entirety  plays  in 
the  emission  of  the  singing  voice,  the  role  of  a 
powerful  resonating  box." 

Mme.  Alice  Garrigue  Mott:  "Normal  faucial 
tonsils  preserve  the  original  structure  of  the 
throat,  on  which  depends  the  beauty  of  the  in- 
dividual voice." 

Frank  E.  Millet^:  "It  is  especially  the  struc- 
tural differences  between  the  resonant  cavities 
of  individual  singers  that  determine  differences 
of  timbre  or  quality.  There  are  innumerable 
timbres  for  the  human  voice,  as  many  as  there  are 
voices,  and  all  due  to  the  pliability  of  the  vocal 
tract.  The  walls  of  the  pharynx  are  permeated 
by  a  network  of  muscles,  susceptible  of  numer- 
ous adjustments  and  re- adjustments  in  size  and 
shape.  The  vocal  tract  of  an  accomplished  singer 
is  capable  of  some  16,000  adjustments  and  re- 
adjustments, as  many  changes  as  a  sensitive  face 
is  of  changes  in  expression." 

"There  are  seventy-four  muscles  and  sixteen 
nerves  capable  of  influencing  various  points  of 
the  vocal  apparatus,  and  by  an  arithmetical  pro- 
gression we  arrive  at  the  enormous  sum  of  74,- 
682,000  possibilities  of  different  combinations  in 
the  action  of  these  muscles." 

"That  is,  granting  that  they  have  individual 
and  conjoint  action  and  do  not  act  in  pairs,  we 
have  the  gigantic  possibilities  of  74,682,000  alter- 
ations in  the  vocal  mechanism.  For  every  tone 
produced,  there  is  a  special  adjustment  through- 
out the  entire  vocal  tract." 


PHYSIOLOGY    OF    THE    TONSIL  57 

One  may  well  conceive  the  ease  and  certainty 
with  which  such  a  mechanism  will  become  de- 
ranged by  the  removal  of  a  tonsil.  It  will  alter 
the  entire  mechanism. 

(2)  The  mis-use  of  the  voice  by  an  incorrect 
method  in  singing  or  speaking  acts  in  a  mechan- 
ical way  in  causing  enlargement,  or  disease,  of  the 
tonsil. 

An  incorrect  method  of  voice  production  de- 
ranges the  voice  mechanism.  Expert  laryngo- 
logists,  and  experienced  voice  trainers,  are 
familiar  with  the  results  of  a  bad  method.  These 
results  with  their  causes  are  noted  in  works  on 
the  voice,  and  have  been  recognized  for  a  long 
course  of  years. 

Tosi,  in  his  "Observations  on  the  Florid  Song, 
1723,"  states:  "When  a  teacher  obliges  the 
scholar  to  hold  out  the  semibreves  with  force 
on  the  highest  notes,  the  consequence  is  that  the 
glands  (tonsils)  of  the  throat  become  daily  more 
and  more  inflamed,  and  if  the  scholar  loses  not 
his  health,  he  loses  the  treble  voice." 

Van  Baggen,  in  the  Medical  Record,  New 
York,  January  5,  1907,  states: 

"Every  specialist  for  throat  diseases  knows 
that  many  of  the  sufferers  from  those  affections 
are  to  be  found  among  those  whose  profession 
demands  constant  use  of  the  voice.  It  is  obvious 
that  the  mis-use  of  the  voice  is  in  most  cases  the 
cause  of  the  affliction." 

"Patients  present  the  following  characteristic 
symptoms:  catarrh  of  the  pharynx  and  of  the 
larynx,  with  congested  and  swollen  mucosa; 
pillars  of  the  fauces  are  swollen  and  often  highly 


58  THE    TONSILS    AND    THE    VOICE 

developed;  paresis  of  the  vocal  cords  which  are 
red  or  yellow  in  color,  and  which  do  not  close 
well.  Paresis  of  the  vocal  cords  is  mostly  united 
with  paresis  of  the  anterior  cricothyroid  muscle, 
the  internal  thyro-arytenoid  muscle,  and  the 
lateral  crico-arytenoid  muscle.  In  some  serious 
cases,  a  swelling  of  the  ary-epiglottic  ligament 
is  observed.    The  fault  is  purely  functional." 

Mine.  Emma  Seller,  in  her  work  on  ''The  Voice 
in  speaking f'  says: 

"By  false  training,  an  artificial  and  unnatural 
way  of  speaking  has  been  formed  by  many  of  our 
orators  and  singers.  The  result  is  that  the  vocal 
organs  very  often  become  diseased.  The  mucous 
membrane  of  the  pharynx  becomes  dry  and  a 
peculiar  huskiness  of  the  voice  occurs.  The  epi- 
glottis becomes  swollen  and  injected.  The  aryten- 
oid cartilages  become  swollen  and  inflamed. 
The  vocal  cords  become  reddened  and  thickened. 
A  slight  paralysis  of  the  cords  is  sometimes  pres- 
ent. The  mucous  membrane  of  the  trachea  be- 
comes congested  and  thickened.  These  are  the 
conditions  of  the  parts  in  typical  cases  of  this 
disease.  But  all  the  symptoms  may  be  aggra- 
vated in  severe  cases  where,  sometimes,  the  ul- 
cerations extend  into  the  trachea  and  up  into  the 
nasal  cavities,  involving  the  Eustachian  tubes  and 
the  middle  ear  in  a  general  sub-acute  inflamma- 
tion. The  real  cause  at  the  foundation  of  the 
disease  consists,  not  in  a  long-continued  use  of 
the  vocal  organs,  hut  in  a  faulty  way  of  using 
themr 

"Straining  of  the  tensor  muscles  of  the  larynx, 
with  added  pressure  of  the  expiratory  muscles 


PHYSIOLOGY    OF    THE    TONSIL  59 

reddens  and  inflames  the  edges  of  the  cords  and 
the  whole  lining  of  the  larynx." 

Shakespeare,  London,  1912,  says:  "I  suspect 
that  most  swollen  tonsils  are  the  result  of  a  rigid 
manner  of  using  the  voice,  both  in  singing  and 
speaking." 

Charles  A.  Rice  states  that:  "Nothing  will 
enlarge  the  tonsils  so  quickly  as  bad  placement 
of  the  voice.  Not  only  are  the  tonsils  enlarged, 
but  the  intrinsic  muscles  are  often  impaired,  and 
sometimes  this  extends  to  a  paralysis  of  the 
arytenoides.  Then  the  tonsils  are  removed,  with 
little  or  no  relief,  for  the  trouble  has  not  been 
with  the  tonsils,  but  caused  by  strain  on  the  en- 
tire vocal  apparatus." 

Enlargement  of  the  tonsils,  caused  by  mis-use 
of  the  voice,  may  lead  to  mechanical  interference 
with  both  deglutition  and  phonation. 

(3)  Tonsils  enlarged,  or  diseased,  through  a 
wrong  method  of  voice  production,  may  he  cured 
by  the  institution  of  a  correct  method. 

When  tonsils  are  enlarged,  or  diseased, 
through  mis-use  of  the  voice,  it  is  plainly  evident 
that  the  only  proper  way  to  cure  them  is  by  re- 
moving the  cause.  Tonsils  enlarged,  or  diseased, 
by  mis-use  of  the  voice  should  not  be  enucleated. 

Mme.  Lilli  Lehmann  states:  "I  never  would 
advise  the  removal  of  anything  from  the  throat 
(of  a  singer)  and  would  always  try  to  cure  it 
without  any  operation.  I  am  quite  sure  that 
every  had  standard  of  health  in  the  throat  can 
be  cured  by  learning  how  to  use  the  right  method. 
Singers  who  sing  well  will  never  be  troubled  by 
anything," 


60  THE   TONSILS   AND   THE   VOICE 

Mme.  Emma  Seller  says:  "The  present  in- 
ability to  preserve  the  voice  is  the  consequence  of 
a  method  of  teaching"  unnatural,  and  therefore, 
imposing  too  great  a  strain  upon  the  voice. 
Voices  which  by  this  overstrained  and  unnatural 
way  of  singing  have  become  worn-out  and  useless 
may  by  correct,  proper  treatment  recover;  and 
even  those  chronic  inflammations  of  the  larynx 
which  are  so  difficult  of  treatment  may  be  cured 
by  a  natural  and  moderate  exercise  of  the  voice 
in  singing." 

(4)  Tonsils  that  are  swollen,  tender  and  pain- 
fid,  caused  hy  mis-use  of  the  voice,  will,  in  turn, 
by  their  abnormal  condition,  hinder  the  proper 
action  of  the  voice  mechanism,  and  this  hindranc. 
will  be  relieved  by  the  proper  use  of  the  voice. 

In  cases  of  this  character,  the  removal  of  the 
tonsils  is  a  blunder. 

(5)  Removal  of  the  normal  faucial  tonsil  in- 
terferes with  the  mechanism  of  the  voice. 

Lermoyez  declares  that  "the  normal,  faucial 
tonsil  is  an  organ  that  must  be  respected.  The 
normal  tonsil  should  never  be  removed  more  than 
a  normal  eye  or  a  normal  tooth." 

Manuel  Garcia  and  Mme.  Viardot-Garcia 
"always  protested  against  any  surgical,  or  other 
artificial  means  for  improving  the  natural  voice." 

Lamperti  states  that  "If  the  tonsils  are  normal, 
they  should  on  no  account  be  removed,  as  the  re- 
moval will  never  improve  the  voice.  In  almost 
all  cases  when  tonsils  were  removed,  I  have  found 
in  the  fifty  years  of  my  teaching,  that  the  voice  is 
injured,  often  beyond  remedy." 

Richard  Loewenherg  says :     "To  prevent  mis- 


PHYSIOLOGY    OF    THE    TONSIL  61 

understanding,  by  normal  tonsils,  I  mean  tonsils 
of  a  healthy  color,  those  not  enlarged  in  length  or 
thickness,  and  showing  no  evidences  of  chronic 
inflammatory  processes.  Such  tonsils  should,  ac- 
cording to  my  experience,  never  be  removed  by 
operations,  neither  on  account  of  the  effect  upon 
the  general  health,  nor  of  the  functional  activity 
of  the  organ  itself.  Even  though  the  physio- 
logical significance  of  the  tonsil  still  rests  upon  a 
hypothesis,  this,  like  any  other  healthy  organ  in 
the  body,  should  be  left  undisturbed.  I  do  not 
know  of  any  case  in  which  a  singer's  voice  was 
improved  by  removal  of  normal  tonsils.  On  the 
contrary,  I  know  of  cases  in  which  the  removal 
of  normal  tonsils  has  caused  permanent  detri- 
mental effects  to  the  voice,  in  consequence  of  the 
unavoidable  injury  to  the  arches  of  the  palate 
(adhesions  scar,  tissue,  etc.) ." 

"For  these  reasons,  I  disapprove  of  operations 
upon  normal  tonsils  in  all  cases." 

Sebastiani  states:  "Often  the  voice  has  been 
damaged  if  the  operation  on  the  tonsils  was  not 
necessary,  but  simply  performed  to  increase  or 
improve  the  voice.  In  similar  cases,  the  voice 
has  been  damaged  and  sometimes  entirely  lost. 
Such  operations  on  so  delicate  an  organ  as  that  of 
the  voice,  are  not  good  for  the  clearness,  exercise, 
color  and  facility  of  the  voice.  The  tissues, 
nerves  and  muscles  always  remain  depreciated 
after  an  operation  that  was  not  compulsory  to 
avoid  greater  damages.  I  would  not  advise  the 
removal  of  normal  tonsils  in  singers.  The  bene- 
fit that  can  be  derived  by  excision  of  the  tonsils, 
if  of  great  utility  in  cases  of  hypertrophy  to  avoid 


62  THE    TONSILS    AND    THE    VOICE 

greater  damages,  may  be  of  some  benefit  to  the 
human  voice  in  general;  but  it  may  not  be  of  any 
benefit  to  specialized  organisms  endowed  with  eoc- 
ceptional  and  valuable  voices.  In  these  cases  of 
exceptional  and  valuable  voices,  any  surgical 
operation  whatsoever,  it  matters  not  how  perfect, 
can  harm  the  precious  instrument/' 

"I  have  been  able  to  verify  that  the  greater  the 
development  of  the  tonsils,  the  more  difficult  is 
the  resonance  and  the  emission  of  the  tones  of  the 
second  register  or  high  notes:  even  the  removal 
of  the  normal  tonsils  does  not  facilitate  these  high 
tones/' 

Mme.  Cappiani  states:  "I  know  of  no  in- 
stance in  which  the  singer's  voice  was  improved 
after  removal  of  the  tonsils.  But  the  voice  may 
be  changed  to  higher  or  lower  pitch.  Often  the 
compass  may  not  be  changed  at  all;  only  the 
sounding  quality  become  more  ordinarj^" 

Mme.  Von  Klenner  states  that  after  removal 
of  the  tonsils  she  "has  always  found  a  certain 
lack  of  sweetness  in  the  tone  quality,  and  difficul- 
ty in  supporting  the  tone  in  certain  registers." 

Hubbard  states  that  "removal  of  the  tonsils 
causes  a  difficulty  in  assuming  different  shapes  of 
the  pharynx  necessarj^  in  singing,  causing  a  hard- 
ness in  quality  and  laborious  action." 

Mme.  Schumann-Heink  states  that  "in  some 
cases  the  voice  becomes  acid,  uncertain,  weak  or 
rough,  or  entirely  ruined  after  removal  of  the 
tonsils." 

Bispham  remarks  that  "there  is  always  trouble 
after  operations  on  the  throats  of  singers;  that 
after  removal  of  the  tonsils  there  is  always  some- 


PHYSIOLOGY    OF   THE    TONSIL  63 

thing  gone  which  contributed  to  the  good  singing 
tone." 

Mme.  Clara  Kathleen  Rogers  declares  that  "the 
tonsils  are  factors  in  forming  the  perfect  resona- 
tor." 

Mme,  Alice  Garrigue  Mott  states  that  "the 
tonsils  preserve  the  original  structure  of  the 
throat,  on  which  depends  the  beauty  of  the  indi- 
vidual voice." 

Von  Schrotter  (Vienna),  Von  Chiari  (Vien- 
na), Schmiegelow  (Copenhagen),  Van  Bag  gen 
(The  Hague),  Lubet-Barbon  (Paris),  Semon 
(London),  Masm  (Naples),  jEJsca^  (Toulouse), 
Moure  (Bordeaux),  Lermoyez  (Paris),  Frdnkel 
(Berlin),  Von  Levinstein  (Berlin),  Brieger 
(Breslau),  Goerke  (Breslau),  Loewenberg 
(Berlin),  Marage  (Paris),  Casteoc  (Paris), 
Gleitsmann,  (New  York) ,  Barth  (Leipzig) ,  Luc 
(Paris,  Miller  (New  York),  Lamperti  (Ber- 
lin), Shakespeare  (London),  De  Reszke 
(P avis) ,  Sebastiani  {'N a-ples),  Sabatini  (Milan), 
Mme.  Lilli  Lehmann  (Berlin),  Mme.  Luisa 
Cappiani  (New  York),  Mme.  Alice  Garrigue 
Mott  (New  York),  Mme.  Schumann-Heink 
(New  York),  Mme.  Lillian  Nordica  (New 
York),  Mme.  Luisa  Tetrazzini  (New  York), 
Bond  (New  York),  Bispham  (New  York),  and 
all  other  authorities,  without  exception,  advise 
against  the  removal  of  normal  tonsils. 

(6)  The  presence  of  the  faucial  tonsil  being 
essential  as  a  factor  in  voice  production,  its  ab- 
sence necessarily  interferes  with  the  perfect  ac- 
tion of  the  mechanism. 

(7)  The  mere  absence  of  the  faucial  tonsil  im- 


64  THE    TONSILS    AND    THE    VOICE 

j)airs  and  weakens — and  the  presence  of  adhe- 
sions, scars  and  contractions  incidental  to  its  re- 
moval, interferes  with  the  mechanism  of  the  voice. 

The  presence  of  the  faucial  tonsil  having  been 
shown  to  be  absolutely  necessary  to  artistic  sing- 
ing and  public  speaking,  is  it  not  reasonable  to 
think  that  its  mere  absence  will,  at  times,  account 
for  deterioration  in  tone? 

The  absolute  certainty  of  impairment  of  the 
voice  which  follows  removal  of  the  tonsil,  I  have 
shown  to  be  well  known  to  the  voice  profession. 

The  phonetic  value  of  the  tonsil  is  proved  by 
the  phonetic  defects  which  always  follow  after 
enucleation. 

For  every  tone  produced  there  is  a  special  ad- 
justment throughout  the  entire  vocal  tract. 
How,  then,  can  enucleation  fail  to  alter  the  mech- 
anism? 

''The  faucial  tonsils  are  absolutely  necessary  in 
the  modulation  of  the  singing  voice."  (Lani- 
perti. ) 

"The  tonsils  regulate  pillar  action/'    (Miller.) 

"They  modulate  the  voice.  They  soften  the 
tone  and  regulate  resonance.  They  assist  in 
changing  the  shape  of  the  pharyngeal  cavity,  and 
the  pitch  and  quality  of  vocal  tone."  (Van  Bag- 
gen.) 

"They  prevent,  in  a  degree,  the  nasal  tone  of 
voice."     (Moure.) 

"Excision  of  the  tonsils,  if  of  great  utility  in 
cases  of  hypertrophy  to  avoid  greater  damages, 
may  be  of  some  benefit  to  the  voice  in  general: 
it  may  not  be  of  any  benefit  to  specialized  organ- 
isms,   endowed   with    exceptional   and  valuable 


PHYSIOLOGY    OF    THE    TONSIL  65 

voices,  these  voices  being  of  great  value  precise- 
ly on  account  of  their  mucosae;  for  the  softness 
of  the  muscles  and  nerves;  for  the  perfection  of 
the  different  cavities  of  resonance;  finally  for  the 
marvelous  structure  of  all  the  vocal  passage. 
Then  in  these  uncommon  conditions  any  surgical 
operation  whatsoever^  it  matters  not  how  perfect, 
can  cause  harm  to  the  precious  instrument. 
Often  the  voice  has  been  damaged  if  the  opera- 
tion on  the  tonsils  were  not  necessary,  but  simply 
performed  with  the  desire  to  increase  or  improve 
the  voice.  The  voice  has  been  damaged  and 
sometimes  entirely  lost.  It  is  not  well  for  the 
clearness,  exercise,  color  and  facility.  The  tis- 
sues, nerves  and  inuscles  always  remain  depre- 
ciated from  an  operation  that  was  not  compul- 
sory to  avoid  greater  damages."     (Sebastiani.) 

"When  removed,  I  have  always  found  a  cer- 
tain lack  of  sweetness  in  the  tone  quality  and 
difficulty  in  supporting  the  tone  in  certain  regis- 
ters."   {Mme.  von  Klenner.) 

"After  removal  of  the  tonsils  the  voice  perma- 
nently loses  much  of  its  personal  quality.  The 
tone  seems  dispersed,  and  lacks  the  usual  bril- 
liancy of  resonance."      {Mme.  Marie  Everett.) 

"Removal  of  tonsils  causes  a  difficulty  in  as- 
suming different  shapes  of  the  pharynx  necessary 
in  singing,  causing  a  hardness  in  quality  and  la- 
borious action."     (Hubbard.) 

"They  preserve  the  original  structure  of  the 
throat,  on  which  depends  the  beauty  of  the  indi- 
vidual voice.  I  know  many  cases  where  the  re- 
moval of  tonsils  has  made  a  change  for  the  worse 
in  quality,"  {Mme.  Matt.) 
6 


66  THE    TONSILS    AND    THE    VOICE 

A  troublesome  tonsil  should  never  he  removed 
if  the  affection  from  which  it  suffers  is  disease 
which  arises  from  a  mechanical  cause  and  which 
disappears  when  the  cause  has  been  removed. 

I  have  proved  that  the  tonsil  plays  an  impor- 
tant role  in  the  mechanism  of  voice  production; 
that  the  mis-use  of  the  voice  causes  enlargement, 
or  disease  of  the  tonsil;  that  enlargement  or  dis- 
ease of  the  organ  may  be  cured  by  correct  use  of 
the  voice ;  that  swollen,  tender  and  painful  tonsils 
hinder  the  normal  action  of  the  voice  mechanism ; 
that  removal  of  the  normal  faucial  tonsil  always 
affects  the  mechanism  and  always  injures  the 
quality  of  voice;  that  the  presence  of  the  faucial 
tonsil  being  an  essential  factor  in  the  voice 
mechanism,  its  absence  necessarily  interferes  with 
the  perfect  action  of  the  mechanism,  or,  in  other 
words,  any  interference  with  the  mechanism  of 
the  voice  leading  to,  or  caused  by,  inechanical  af- 
fection of  the  faucial  tonsil,  will  become  a  posi- 
tive and  perniane7it  injury,  if  the  tonsil  is  re- 
moved; that  such  an  egregious  blunder  as  the  re- 
moval of  an  integral  part  of  the  mechanism  of 
the  voice  cannot  possibly  be  atoned  for. 

Precious  voices  have  the  most  delicate  mechan- 
ism; the  more  delicate  the  mechanism,  the  more 
easily  it  is  thrown  out  of  order. 

The  natural  mechanism  of  the  voice  can  never 
be  improved  by  surgical  means.  The  throat  of 
the  voice  user  requires  more  consideration  and  less 
treatment  than  any  other  throat. 

There  are  no  opj)ortune  times  at  which  a  voice 
user's  throat  requires  radical  treatment,  or  sur- 


PHYSIOLOGY    OF    THE    TONSIL  67 

gical  operation,  with  any  assurance  of  improving 
the  voice. 

Hyperplasias.  Enlargement  of  the  faucial 
tonsil  may  be  temporary,  or  permanent.  En- 
largement is  due  to  a  great  variety  of  causes,  and 
presents  many  structural  variations.  Differen- 
tial diagnosis  of  the  various  forms  is  essential  for 
the  proper  application  of  treatment.  Diagnosis 
is  of  no  value  to  those  alone  who  consider  it  of  no 
importance,  or  who  minimize  it  in  favor  of  abla- 
tion. 

Under  a  variety  of  conditions,  cells,  larger 
parts  of  the  body,  or  entire  organs  become  larger 
than  normal.  The  structural  change  may  be  a 
simple  increase  in  size  of  the  elementary  structure 
of  the  part,  the  cells.  This  is  simple  hypertro- 
phy. It  is  usually  associated  with  some  increased 
functional  demand  upon  the  cells  and  an  increase 
in  their  functional  capacity. 

On  the  other  hand,  in  many  cases  the  increase 
in  size  of  a  part  or  organ  is  due  not  only,  or  not 
at  all,  to  the  increase  in  size  of  its  elementary 
structures,  but  to  an  increase  in  their  number. 
This  increase  in  number  of  the  structural  ele- 
ments of  a  tissue  or  organ  is  called  numerical 
hypertrophy,  or  hyperplasia. 

Simple  hypertrophy  and  hyperplasia  are  fre- 
quently associated. 

Simple  enlargement  of  a  part  or  organ  does 
not  necessarily  involve  hypertrophy  of  any  of  its 
structural  elements.  It  is  well  to  limit  one's  con- 
ception of  hypertrophy  to  enlargement  of  specific 
structural  elements  of  a  part  with  maintenance  or 
increase  of  functional  activity,  and  to  consider 


68  THE    TONSILS    AND    THE    VOICE 

other  instances,  as  increase  of  fat  in  a  muscle,  or 
wax}^  degeneration  of  the  liver,  as  examples  of 
pseudo-hypertrophy. 

Compensatory  hypertrophy  of  the  thyroid  and 
adrenals  has  been  eccperimentally  induced. 

In  most  of  these  conditions  hj^perplasia  of  the 
interstitial  tissue  is  associated  with  parenchyma 
hypertrophy  of  the  specific  parenchyma  cells 
whose  response  to  increased  functional  demands 
is  marked  by  simple  hj^pertroph}^ 

Lymph-nodes,  in  addition  to  considerable 
hyperplasia  due  to  inflammation,  also  become  en- 
larged under  a  variety  of  conditions  which  we  do 
not  understand.  This  lack  of  knowledge  of  the 
etiology,  together  with  our  ignorance  of  certain 
functions  of  the  lymph-nodes,  and  the  morplio- 
logical  similarity,  or  even  identity,  which  these 
enlarged  nodes  present  under  various  conditions, 
render  it  very  difficult  to  decide  upon  the  exact 
nature  of  the  change,  and  in  many  cases  to  dis- 
tinguish one  form  of  enlargement  from  another. 

Acute  inflammation  of  the  tonsil  shows  an  in- 
creased infiltration  with  leucocj^tes,  which  causes 
enlargement,  also  increased  amount  of  lymph  in 
the  intercellular  spaces. 

Congestion  by  tymph,  or  increase  in  adenoid 
tissue,  are  not  the  only  reasons  for  enlargement. 

So  manj^  of  the  most  profound  thinkers  con- 
sider enlargement  of  the  tonsil  to  be  sometimes 
symptomatic  of,  or  associated  with,  in  some  way, 
the  growth  of  the  individual,  that  it  is  wise  to 
respect  this  observation.  It  is  well  to  heed  Escat, 
who  is  "of  the  opinion  that  the  faucial  tonsil  has 
not  for  its  only  function  that  of  phagocytosis  as 


PHYSIOLOGY    OF    THE    TONSIL  69 

studied  by  Metchnikoff,  but  also  a  physiological 
and  biological  function  due  to  an  internal  secre- 
tion." 

"I  claim,  in  accord  with  the  opinion  of  Allen, 
that  the  tonsil  secretes  a  principle  which  we  are  as 
yet  unable  to  determine,  but  which  should  be  use- 
ful in  the  develo23ment  and  growth  of  the  subject, 
and  probably  to  the  growth  of  the  skeleton.  I 
have  found  a  reason  for  this  in  the  fact  that  the 
normal  tonsils  atrophy  normally  at  about  the  age 
of  18  to  20  years,  from  the  time  that  the  subject 
has  become  fully  an  adult." 

Brieger  states  that: 

"(1)  Enlargement  of  the  tonsil  by  lymphatic 
scrofula  has  not  been  proved. 

(2)  Clinical  aspect  is  conditioned  by  tuber- 
culosis in  a  certain  number  of  cases. 

(3)  In  very  rare  cases  the  hyperplasia  is  pro- 
duced by  lues. 

(4)  Hyperplasia  of  the  glands  appears  in  the 
whole  lymphatic  apparatus  accompanying  en- 
largement of  the  tonsils. 

These  four  represent  only  a  minority  of  the 
cases. 

Generally  they  are  very  healthy  people  who 
have  enlarged  tonsils." 

According  to  Grober:  "The  tonsils  seem  to  be 
a  less  favored  settling  place  for  tubercle  bacilli 
than  the  lymph  glands,  for  we  find  scrofulous 
glands  oftener  than  infection  of  the  tonsils. 
Many  authors  consider  diseased  tonsils  as  more 
liable  to  microbial  infection  than  healthy  ones. 
If  that  is  true,  it  has  not  been  proved." 

"It  has  been  shown  that  the  entrance  of  mi- 


70  THE    TONSILS    AND    THE    VOICE 

crobes  into  the  system  does  not  always  produce 
the  disease.  It  is  important  how  strong  the  de- 
fensive processes  of  the  body  are.  Therefore, 
infectious  diseases  are  mostly  constitutional." 

Goerke  asks:  "What  are  the  causes  of  the  in- 
volution of  the  tonsils,  and  its  importance  for  the 
organism  ? 

Answer.  Involution  is  an  expression  of  im- 
munity against  certain  infections  especially  pecu- 
liar to  childhood. 

(2)  What  are  the  microscopic  (and  macro- 
scopic) changes  of  the  involution? 

Answer.  Disappearance  of  follicular  tissue, 
and  appearance  of  indifferent  tissue. 

(3)  How  does  the  final  result  of  involution 
represent  itself  histologically? 

Answer,  As  a  picture  of  the  normal  mucous 
membrane  of  the  pharynx. 

(4)  What  are  the  causes  that  prevent  involu- 
tion, and  how  do  we  learn  these  causes  by  histo- 
logic examination? 

Answer.  Inflammatory  processes,  in  the  up- 
per part  of  the  pharynx,  or  in  the  tonsil  itself. 

(5)  What  picture  represents  the  tonsil  not 
completely  involved? 

Answer.  By  changes  connected  with  inflam- 
matoiy  processes. 

( 6 )  How  will  therapy  be  directed  ? 
Answer.     As  we  are  not  able  to  bring  about 

involution  of  the  tonsils  in  adults,  the  tonsils 
must  be  removed  by  operation." 

Goerke  states:  "After  operation,  the  tissue 
regrows,  and  in  this  way  seems  like  a  lympho 
sarcoma." 


PHYSIOLOGY    OF    THE    TONSIL  71 

"Tuberculosis  is  of  no  importance  as  regards 
hyperplasia  or  return  of  the  growth.  The  ade- 
noid tissue  regenerates  in  all  cases,  after  removal 
of  the  tonsil.  Those  same  causes  which  led  to 
the  first  hyperplasia  also  lead  to  the  new  hyper- 
plasia. These  recurrences  occur  more  often  than 
we  think,  hut  we  do  not  know  about  them.  Pa- 
tients don't  speak  about  the  return,  because  they 
dont  want  to  be  operated  on  again.  The  re- 
growth  is  never  as  great  as  the  first  hyperplasia.^' 

Grober  says:  "It  is  not  possible  to  remove 
the  entire  tonsil." 

Marage  says:  "Lymphoid  tissue  always  es- 
capes in  surgical  intervention  no  matter  how  well 
it  is  done." 

Von  Levinstein  saj^s:  "Its  total  removal  is 
not  possible." 

Escat  says:  "Even  in  the  most  radical  abla- 
tion of  the  tonsil,  there  is  alwaj^s  left  a  little  ade- 
noid tissue.  It  is  not  necessary,  in  my  opinion, 
to  set  one's  heart  upon  completely  extracting  all 
the  tonsillar  tissue  as  various  American  con- 
freres proposed.  The  tonsil  is  not  a  cancer! 
After  ablation,  a  kind  of  anaemia  or  weakness, 
a  cachexia  tonsilliprive,  has  sometimes  occurred." 

Moure  and  IE  scat  state  that  "the  lingual  tonsil 
sometimes  overlaps  and  becomes  blended  with 
the  faucial  tonsil." 

Truth  demands  a  record  of  the  statement, 
noted  by  many  excellent  observers,  that  a  new 
growth  occurs  at  the  seat  of  the  tonsil,  after  that 
organ  has  been  removed.  So  constant  is  the  oc- 
currence of  this  new  growth  that  it  must  he  con- 
sidered as  the  result  of  a  natural,  sequential, 


72  THE    TONSILS    AND    THE    VOICE 

physiological  process.  The  growth  must  per- 
forin some  physiological  function^  for  nature 
never  serves  a  useless  purpose. 

Lennooj  Browne  says:  "Beyond  any  ques- 
tion, there  is  a  tendency  not  of  recurrence  but  a 
continuation  of  the  growth." 

Von  Levinstein  says :  "Eradication  of  the  ton- 
sil can  never  be  completely  done.  A  total  and 
lasting  destruction  of  the  tonsillar  tissue  is,  as 
Goerke  has  proved,  absolutely  impossible,  for  it 
regenerates  always." 

Brieger,  Wright,  Semon,  Mackenzie  and 
Grayson  agree  with  Goerke,  Groher,  Levinstein, 
Escat  and  Browne. 

Jacohi  says:  "It  is  not  a  matter  of  indiffer- 
ence whether  the  capsule  of  the  tonsil  is  removed 
or  not.  Infection  through  the  capsule  is  rather 
difficult.  The  capsule  is  a  protection  to  the 
blood  and  lymph  circulation." 

The  capsule  is  a  harrier  in  preventing  the  ex- 
tension of  disease  from  within  the  tonsil  to  neigh- 
boring tissues  in  its  vicinity.  The  capsule  is  a 
barrier  in  p)r eventing  the  extension  of  disease  to 
the  body  of  the  tonsil  froin  the  outside  neighbor- 
hood. 

The  capsule  protects  the  tonsil  against  ex- 
ternal injury.  It  adds  solidity  to  the  structure 
of  the  tonsil,  and  contributes  a  degree  of  firmness 
to  the  faucial  wall. 

I  view  the  tonsils  as  BUFFER  ORGANS. 
They  are  buffers.  From  their  plainly  visible  ac- 
tion, I  would  call  these  bodies  FAUCIAL 
CUSHIONS.  They  are  cushions.  They  un- 
doubtedly serve  as  cushions  to  the  pharynx.  They 


PHYSIOLOGY   OF   THE   TONSIL  73 

are  mechanical  cushions.  They  are  acoustic  cush- 
ions. 

The  act  of  swallowing  involves  consideration 
of  the  faucial  tonsils.  In  the  act  of  swallowing 
the  upper  part  of  the  tonsil  is  pressed  downward 
and  inward  between  the  pillars  of  the  fauces. 
The  inferior  constrictors  of  the  pharynx  contract 
above,  upon  the  morsel  of  food,  and  force  it 
downward  into  the  aesophagus.  The  palato- 
pharyngeus  draws  the  palate  down  upon,  and  the 
sides  of  the  pharynx  in  upon,  the  food,  to  force 
it  downward.  It  also  aids  in  swallowing  by 
drawing  the  larynx  upward. 

In  the  act  of  swallowing,  as  the  mass  of  food 
passes  through  the  pharynx,  from  the  mouth  to 
the  aesophagus,  the  side  walls  of  the  pharynx  ap- 
proach each  other  and  press  upon  the  passing 
bolus,  imparting  to  it  a  slight  push  downward. 

The  faucial  tonsils  occupy  the  forefront  of  the 
push.  A  morsel  of  fish  containing  a  sharp  bone, 
when  pressed  upon,  may  pierce  the  tonsil  without 
evil  result,  without  pain,  without  bleeding.  In 
this  way  the  tonsil  acts  mechanically  both  as  a 
huf'er  and  as  a  cushion,  and  serves  to  protect  the 
more  delicate  and  important  structures  of  the 
pharynx  and  larynx. 

If  the  tonsils  are  removed,  then  delicate  and 
important  blood  vessels,  nerves  and  muscles  be- 
come exposed.  Immediately  behind  the  tonsil  is 
placed  the  internal  carotid  artery — the  size  of  a 
goose  quill.  Prick  that!  and  you  will  quickly 
see  what  happens.  The  tonsil  protects  the  inter- 
nal carotid  artery.  Its  absence  menaces  this  ar- 
tery.    The  internal  carotid  artery  is  twice  threat- 


74  THE    TONSir.S    AND    THE    VOICE 

ened  by  tonsillectomy;  first  by  the  operation,  and 
second,  by  the  absence  of  the  tonsil. 

"The  physiological  act  of  deglutition  is  some- 
times considerably  disturbed  in  affections  of  the 
oro-pharynx  and  of  the  laryngo-pharynx.  En- 
largement of  the  lingual  tonsil,  acute  or  chronic 
inflammation,  and  tumors  at  the  base  of  the 
tongue  having  their  seat  in  the  region  of  the  epi- 
glottic fossettes,  where  the  alimentary  bolus  is 
formed  at  the  beginning  of  deglutition,  are,  above 
all,  characterized  by  a  constant  sensation  of  a 
false  alimentary  bolus,  which  greatly  incom- 
modes the  patient."     (Escat.) 

In  the  presence  and  also  in  the  absence  of 
these  conditions,  I  have  repeatedly  observed 
elderly  persons  incommoded^  and  sometimes 
choke,  at  the  very  beginning  of  the  act  of  swal- 
lowing on  account  of  an  apparent  slowing-up  m 
the  process  of  muscular  contraction  of  the  mus- 
cles of  the  pharynx — a  sort  of  semi-paresis.  I 
was  once  called  into  consultation  in  the  case  of  an 
old  gentleman,  whose  family  physician  had  diag- 
nosticated "paralysis  of  the  epiglottis  and  of  the 
vocal  cords,"  and  was  about  to  perform  trache- 
otomj^,  but  in  which  case  I  changed  the  diagnosis 
to  that  of  inflammation  of  the  fossettes  with  ab- 
normally slow  muscidar  action.  He  recovered 
promptly  without  an  operation. 

It  admits  of  no  question  that,  sometimes,  in 
elderly  people,  abnormally  slow  muscular  move- 
ments will  be  made  still  slower  by  removal  of  the 
tonsils,  and  that  this  will  particularly  follow  in 
cases  of  removal  of  unusually  enlarged  tonsils 


PHYSIOLOGY   OF   THE   TONSIL  75 

which  pressed  upon,  and  gave  support  to,  the 
palatine  arches. 

Medical  authorities  have  furnished  no  proof 
and  are  entirely  undecided  regarding  any  pos- 
sible physiologic,  biologic,  or  bio-chemical  func- 
tion of  the  faucial  tonsil. 

I  have  presented  the  evidence  and  have  fur- 
nished the  proof  that  the  voice  mechanicians 
(physicists,  acousticians,  phoneticians),  voice 
trainers,  and  voice  users,  agree  that  the  faucial 
tonsil  possesses  important  mechanical,  acoustic 
and  phonetic  functions. 

While  I  have  shown  that  the  faucial  tonsil  pos- 
sesses highly  important  mechanical,  acoustic  and 
phonetic  functions,  I  also  believe  that  the  anat- 
omy of  this  organ,  with  its  germinating  centers, 
and  with  its  curious  system  of  closed  lymphatic 
canals  indicates  hio-chemical  and  physiologic 
functions  which,  as  yet,  have  not  been  proven. 

The  learned  hypothesis  of  Brieger  and  Goerke 
seems  to  deserve  the  high  endorsement  of 
Frdnkel.  And  the  theory  of  Allen,  endorsed  by 
Escat  and  other  high  authorities  is  surely  worthy 
of  further  research.  Von  Lendrfs  proof  of  a 
direct  lyn^phatic  communication  between  the 
nose  and  the  tonsil  is  important.  He  has  also 
proved  an  intimate  connection  existing  between 
the  two  faucial  tonsils.  And  Poli  has  shown 
that  the  lymphatic  region  of  the  two  nostrils  com- 
municate by  anastomotic  branches  which  at  the 
back  surround  the  free  edge  of  the  septum  and 
at  the  front,  though  to  a  less  degree,  by  vessels 
which  pierce  the  septal  cartilages. 


CHAPTER  IV 
CAUSES  OF  TONSIL  DISEASES. 

A  clear  understanding  of  the  normal  anatomy 
and  physiology  of  any  organ  is  essential  to  a 
clear  conception  of  the  cause  of  the  disease  that 
may  affect  it.  Disease  is  an  interruption  of 
function,  not  something  new,  not  something 
added  to,  hut  an  interference  with  physiological 
action. 

Injury  of  a  cell  by  bacteria,  toxins  or  other 
means  disturbs  its  function.  Agencies  and  con- 
ditions to  which  the  body  has  not  adapted  itself 
which,  swaying  its  normal  capacities  now  one 
way  and  now  another,  induce  the  functional 
alterations  by  which  disease  is  manifested.  It 
follows  from  this  that  the  functional  abnormali- 
ties and  the  structural  alterations  which  make  up 
the  signs,  symptoms  and  lesions  of  disease  in- 
volve the  expression  of  no  new  functional  capaci- 
ties which  the  normal  body  does  not  possess. 

The  body  in  disease  manifests  no  new  func- 
tions, develops  no  new  forms  of  energy ,  reveals 
no  new  capacities. 

In  normal  physiology  attention  is  most  keenly 
centered  to-day  upon  the  structure  and  per- 
formance of  cells  as  the  field  richest  in  the  prom- 
ise of  significant  revelations. 

Soj  also,  in  pathology  by  similar  methods  and 
with  equal  persistence  must  the  structure  and 
performance  of  cells  under  abnormal  conditions 
be  studied  if  we  are  to  hope  with  reason  for  a 
clearer  comprehension  of  disease, 

76 


CAUSES   OF    TONSIL   DISEASES  77 

To  the  conception  of  pathological  processes  as 
essentially  cellular  processes  are  due  the  great 
advances  which  this  phase  of  biological  science 
has  made  during  the  past  few  decades. 

When  we  study  the  causes  of  diseases,  we 
should  remember  always  that  underlying  the 
manifestations  of  disease  as  well  as  sustaining 
the  correlated  processes  which  we  name  health, 
are  the  complex  and  ceaseless  chemical  transfor- 
mations which  in  both  health  and  disease  alike 
supply  the  energy  which  sustains  all  expression 
of  life.  So  that  what  we  are  wont  to  call  the 
senses,  whether  external  or  internal,  of  disease 
are  really  not  primary  causes,  but  liberating  im- 
pulses or  excitants  which  sway  and  modify  the 
orderly  transformations  of  energy  constituting 
health  with  those  manifestations  of  perturbed 
function  or  altered  structure,  or  both,  on  which 
our  conceptions  of  disease  are  framed. 

Delafield  and  Prudden  (Text-hook  of 
pathology)  : 

"Pathology,  then,  deals  with  the  disturbances 
of  function  and  the  alterations  of  structure  in 
living  beings,  induced  by  unusual  agencies  and 
conditions." 

"The  functional  disturbances  thus  induced  are 
embraced  as  symptoms  of  disease  in  pathological 
physiology,  which  so  largely  dominates  the  scien- 
tific activities  of  the  physician,  and  forms  the 
basis  for  the  practice  of  his  art." 

"Furthermore,  so  much  depends  upon  the 
metabolism  of  the  body  in  health  and  disease  that 
it  is  to  chemistry,  both  physiological  and  patho- 
logical, that  the  scientific  physician  looks  most 


78  THE    TONSILS    AND    THE    VOICE 

eagerly  for  the  solution  of  problems  which  each 
day  become  more  numerous  and  urgent." 

A  knowledge  of  the  processes  of  bacterial  inva- 
sion, of  the  process  of  phagocytosis,  of  the  action 
of  opsonins,  is  essential  to  the  understanding  of 
the  causes  of  tonsil  affections.  The  air  we  breathe, 
the  food  and  drink  we  swallow,  are  carriers  of 
bacteria,  toxins,  and  other  deleterious  matters. 
The  nose  and  mouth  are  open  avenues  for  inva- 
sion. 

The  presence  of  pathogenic  micro-organisms 
and  other  deleterious  substances  often  interfere 
with  the  normal  condition  of  the  tonsil.  Blood 
serum,  and  other  body  fluids,  are  capable  of  kill- 
ing bacteria  with  which  they  come  in  contact. 
Even  more  than  in  the  action  of  living  phagocy- 
tes the  protective  agencies  are  to  be  sought  in  the 
body  fluids.  The  importance  of  this  protective 
power  of  body  cells  and  body  fluids  is  not  ex- 
hausted with  their  germicidal  action.  Not  less 
significant  is  the  role  which  these  may  assume  in 
the  establishment  of  other  phases  of  immunity. 
Other  exudates,  serum,  and  fibrin  may  be  useful 
to  the  individual  in  the  dilution  of  locally  engen- 
dered poisons  and  in  their  removal  from  a  \Tilner- 
able  region  the  fluid  may  at  times  be  beneficial. 

Fibrin,  too,  by  closing  inflammatory  foci, 
through  temipOYSLTy  adhesions,  or  by  the  healing 
of  absorbent  surfaces,  may  limit  the  extension 
of  the  injurious  agents.  This  is  the  very  point 
that  Jacohi,  in  the  Archives  of  Pediatrics,  insists 
upon,  namely:  that  where  a  lesion  occurs  on  the 
surface  of  the  tonsil,  invasion  of  germs  does  not 
take  place;  first,  because  of  the  impaction  of  the 


CAUSES    OF    TONSIL    DISEASES  79 

tissue  with  fibrin ;  second,  because  of  the  bacteri- 
cidal influence  of  the  stagnating  venous  blood. 
That  the  regenerations  and  repair  of  tissue  which 
may  be  associated  with  or  follow  the  more  active 
phases  of  inflammation  are,  as  a  rule,  beneficent, 
is  not  doubtful.  Inflammation  is  the  local  at- 
tempt at  the  repair  of  injur}^  The  fundamental 
conception  upon  which  this  characterization  is 
based  is  that  inflammation  is  an  emergency  meas- 
ure incited  by  injurj^,  in  which  the  body  adapts 
to  unusual  ends  as  best  it  can  mechanisms  and 
processes  normally  maintained  for  other  purposes. 
This  view  of  inflammation  points  the  way  to  a 
broader  interpretation  of  other  abnormal  condi- 
tions in  which  also  the  adaptation  of  physiologi- 
cal cell  capacities  to  new  conditions  seems  to  fur- 
nish a  clue  to  many  manifestations  of  disease  as 
yet  but  little  understood. 

Delafield  and  Prudden  say:  "In  the  light  of 
the  new  knowledge  of  opsonins  and  their  rela- 
tion to  phagocytosis,  the  recurrence  of  leucocy- 
tosis  in  various  affections  becomes  of  special  sig- 
nificance. For  if  either  a  local  or  general  leu- 
cocytosis  be  fostered  hand  in  hand  with  the  effec- 
tive production  of  opsonins,  the  conditions  would 
appear  to  be  most  favorable  for  the  control  of  the 
infective  process." 

Leucocytes  are  apt  to  gather  in  regions  in 
which  micro-organisms  are  abundant,  and  are  be- 
lieved to  take  up  and  destroy  micro-organisms 
and  to  prevent  further  entrance,  and  possibly  the 
entrance  of  their  products  also,  into  the  circula- 
tion. The  leucocytosis  of  infectious  diseases 
may  be  regarded  as  the  effort  of  the  blood  pro- 


80  THE    TONSILS    AND    THE    VOICE 

ducing  organs  to  protect  the  blood  and  tissues  by 
means  of  leucocytes  against  the  invasion  of 
micro-organisms  and  against  the  actions  of  tox- 
ins present  in  the  circulation.  It  is  quite  possible 
that  in  the  blood  stream  leucocytes  act  as  scaven- 
gers. According  to  Metchnikoff,  leucocytes  are 
manufacturers  and  storehouses  both  of  immune 
bodies  and  complements.  Hyperaemia  must  be 
viewed  as  a  protective  process.  Increased  blood 
supply  to  any  part  means  an  increase  in  the  num- 
ber of  leucocytes.  Acute  inflammation  is  a 
heightening  of  this  process,  caused  by  the  pres- 
ence of  bacteria,  toxins  or  other  noxious  matter. 
Increased  blood  supply  means  a  flushing  of  the 
part  with  defensive  and  protective  leucocytes, 
and  at  the  same  time  sustaining  super-nutrition 
under  conditions  of  distress.  The  inflammatory 
exudates  are  salutary  in  that  they  clean  the  tis- 
sues and  wash  away  bacteria,  toxins  and  other 
debris.  The  object  of  inflammation  is  always 
salutary.  Acute  hyperaemia  and  the  flow  of 
secretions  should  be  encouraged,  not  interfered 
with. 

The  new  light  upon  inflammation  bears  with 
particular  force  upon  the  infections  of  the  region 
of  the  tonsils,  peri-tonsil,  adenoid  structures,  the 
nose  and  mouth.  Westenhoeffer  has  proved 
that  the  germs  of  cerebro-spinal  meningitis  enter 
the  system  by  way  of  the  nose  and  through  the 
pharyngeal  tonsil,  after  the  protective  power  of 
that  tonsil  has  been  broken  down  by  the  superior 
force  and  the  virulency  of  the  invading  germs. 

Fi^dnheVs  statement  that  the  faucial  tonsil  be- 
comes infected  from  the  invasion  of  germs  from 


CAUSES    OF    TONSIL    DISEASES  gl 

the  nose  by  way  of  the  lymphatic  canals  has 
been  proved  by  Von  Lendrt. 

The  faucial  tonsil  becomes  diseased  from  six 
common  sources: 

( 1 )  Prbnary,  by  infection  from  the  mouth,  or 
continuity  of  surface. 

(2)  Secondary,  from  the  nose,  via  the  lym- 
phatic vessels. 

(3)  SyinptomatiCj  representing  general  blood 
disease,  etc. 

(4)  Reftecc  disease,  or  sympathetic,  from  den- 
tal caries,  nasal  affection,  etc. 

(5)  Mechanical,  due  to  pressure,  false  method 
in  using  the  voice,  etc. 

(6)  Hyperplastic. 


CHAPTER  V 

CLASSIFICATION  OF  TONSIL 
DISEASES. 

Anatomical  and  clinical  considerations  are 
both  essential  in  a  practical  classification  of  tonsil 
diseases.  The  anatomy  must  be  kept  in  view. 
The  processes  of  bacteriology  teach  us  that 
wherever  a  specific  infectious  micro-organism  is 
to  be  found,  the  disease  belongs  to  that  organism. 
No  matter  what  organ  or  anatomical  structure 
is  affected,  if  the  bacillus  tuberculosis  can  be 
demonstrated,  it  is  always  tuberculosis.  Present 
knowledge  of  infectious  processes  has  already 
proved  of  great  advantage,  both  theoretically 
and  practically;  treatment  is  surer,  prevention 
more  certain,  and  mortality  is  greatly  lessened. 
But  we  are  still  ignorant  of  a  great  number  of 
infections  and  of  infectious  processes.  Infective 
micro-organisms  are  varied  and  numerous  and 
every  year  adds  to  our  list  of  new  diseases  of 
hitherto  unsuspected  character.  Physiological 
chemistry  is  constantly  adding  new  poisons  and 
reactions,  while  the  sclerotic  and  hyperplastic 
processes  have  much  to  reveal. 

Diseases  of  the  faucial  tonsil  may  be  conveni- 
ently divided  into  six  classes:  (1)  Primary,  (2) 
Secondary,  (3)  Symptomatic,  (4)  Reflex  or 
Sympathetic,  (5)  Mechanical,  (6)  Hyperplasias. 

(1)  The  PRIMARY  diseases  are  those  that 
affect  the  mucous  membrane  covering  the  surface 
of  the  tonsil  and  lining  the  fossulae  or  crypts, 

82 


CLASSIFICATION    OF    TONSIL    DISEASES  83 

namely:  acute  inflammation  of  fossulae — syno- 
nyms— acute  tonsillitis,  acute  lacunar  tonsillitis, 
infectious  tonsillitis,  acute  follicular  tonsillitis, 
cryptic  tonsillitis ;  acute  ulcerative  lacunar  tonsil- 
litis, herpetic  tonsillitis,  membranous  tonsillitis; 
chronic  inflammation  of  fossulae;  lacunar  cal- 
culus— synonym,  tonsillith ;  hyperkeratosis — 
synonyms,  lacunar  hyperkeratosis,  mycosis  lep- 
tothricia ;  actinomycosis;  'pseudo-membranous 
tonsillitis;  diphtheria;  tubercidosis;  lupus;  spe- 
cific. 

(2)  SECONDARY  diseases  affecting  the  in- 
terior of  the  body  of  the  tonsil,  as  infections  from 
nasal  catarrh,  and  nasal  trauma  via  the  lymphatic 
vessels :  secondary  infection  of  the  body,  and  also 
of  the  mucous  membrane  covering  the  surface, 
from  inflammation  or  abscess,  in  the  peritonsillar 
tissues. 

(3)  SYMPTOMATIC  diseases,  due  to  in- 
fection of  the  blood,  tuberculosis,  lues,  exanthe- 
mata, typhoid,  rheumatism,  etc. 

(4)  REFLEX  diseases,  pain,  tenderness, 
swelling,  from  eruption  of  teeth,  nasal  affection, 
etc. 

(5)  MECHANICAL  diseases,  pain,  tender- 
ness, swelling,  etc.,  from  false  method  in  using 
the  voice,  mechanical  pressure,  etc. 

(6)  HYPERPLASIAS,  temporary,  from 
augmented  physiological  function,  absorption  of 
nasal  trauma,  etc. 

Permanent  hyperplasia  from  increase  of  ade- 
noid tissue,  from  tubercular  and  other  infections 
via  the  lymphatic  vessels,  and  also  via  the  general 
blood  current,  etc. 


84  THE    TONSILS    AND    THE    VOICE 

Papilloma,  most  common  growth.  Lipoma, 
rare.     Angioma,  rare. 

Fihro-enchondroma,  rare.  Cystorna,  rare. 
Lymjjhadenoma,  rare. 

Atrophy,  common.  Hypertrophy,  common. 
Submerged  tonsil,  common. 

Carcinoma,  more  malignant  than  sarcoma  and 
equally  rare. 


CHAPTER  VI 
ADENOIDS. 

A  bright,  beautiful,  blue-eyed  little  girl  went 
running  home  from  school  one  day,  in  great 
alarm,  to  tell  her  mother  that  the  school  doctor 
had  examined  her  and  had  told  her  that  she  "had 
adenoids  and  tonsils  and  unless  they  were  taken 
out  she  would  get  an  awful  disease."  "I  was  so 
frightened,"  she  said,  "that  I  cannot  remember 
the  name  of  the  disease  the  doctor  told  me  I 
would  get;  but  I  am  sure  he  said  either  two 
berculosis  or  three  berculosis." 

A  lad  of  twelve  years  told  me  that  the  school 
doctor  had  examined  him.  "He  put  a  stick  in 
my  mouth,  and  said  'You  have  one  large  tonsil 
and  catarrh  in  your  nose.'  The  doctor  had  four 
sticks.  He  examined  seventy -five  in  our  school; 
two  were  normal  and  seventy-three  were  ab- 
normal." 

A  physician  of  over  twenty-five  years'  experi- 
ence, a  graduate  of  the  University  of  Pennsyl- 
vania, called  upon  me  to  examine  his  throat. 
He  remarked  about  adenoids.  I  asked  him  the 
question:  "What  do  you  mean  by  adenoids?" 
After  some  hesitation,  he  replied,  "Adenoids  is 
an  enlargement  of  the  lymphatic  tissues.  I 
think  that  is  what  they  are.  I  have  never  looked 
up  the  definition." 

The  word  adenoid  is  not  a  pathologic  term.  It 
does  not  refer  to  enlargement,  disorder  or  dis- 
ease,    Webster  defines  the  word.     It  is  an  ana- 

85 


-  4 


86  THE    TONSILS    AND    THE    VOICE 

tomical  term,  a  noun,  a  name  applied  to  a  natural 
structure.  Adenoids  are  natural  bodies,  as  nat- 
ural as  your  eyes,  or  your  teeth.  What  they  are, 
where  they  are,  what  they  do,  the  dangers  of  their 
removal,  and  their  return,  are  interesting  ques- 
tions. 

I  The  word,  adenoid,  comes  from  the  Greek 
words,  aden,  meaning  a  gland,  and  eidos,  mean- 
ing like — like  a  gland.  Adenology,  the  doctrine 
of  the  glands.  Ade7iitis,  inflammation  of  a 
gland.  Adenotomy,  a  cutting  or  incision  of 
a  gland.  Adenectomy,  the  complete  removal  of  a 
gland.  Tonsillotomy,  the  partial  removal  of 
a  tonsil.  Tonsillectomy,  the  complete  removal  of 
a  tonsil.  Tonsillectomy  is  synonymous  with 
enucleation.  The  words  adenotomy  and  tonsil- 
lotomy^ are  sometimes  used  synonymously.  So 
are  the  words  adenectomy  and  tonsillectomy. 

There  are  three  sets  of  circulating  channels  in 
the  human  body,  arteries,  veins  and  lymphatics. 
Through  the  lymphatic  vessels  a  fluid  circidates 
which  protects  the  system  from  the  invasion  of 
germs  and  other  deleterious  substances.  This 
fluid,  called  lymph,  contains  a  vast  number  of 
bodies,  microscopic  in  size,  called  lymph  cells, 
lymphocytes,  leucocytes  and  phagocytes.  These 
attack,  digest  and  destroy  germs  and  poisons 
which  gain  entrance  to  the  lymphatic  vessels. 
The  direction  of  the  lymphatic  current  is  alwaj^s 
from  the  surface  toward  the  center  of  the  body. 
Attached  to  the  lymjjhatic  vessels,  especially  those 
surrounding  the  oriflces  of  the  body,  as  in  the 
back  of  the  mouth  and  behind  the  nasal  passages, 
there  are  bodies  called  adenoids.  Different  names 


ADENOIDS  87 

are  given  to  these  bodies.  The  smallest  in  size 
are  called  lymph  nodules,  the  medium,  lymph 
nodes,  and  the  largest,  tonsils.  There  are  count- 
less thousands  of  the  smaller  adenoids  scattered 
about  in  and  underneath  the  lining  membranes 
of  the  mouth  and  the  parts  behind  the  nasal  pas- 
sages. Adenoids  cannot  be  seen  by  the  naked 
eye,  excepting  the  very  largest  size,  called  tonsils. 
And  as  a  rule  only  two  tonsils  can  be  seen ;  those 
placed  on  each  side,  at  the  back  of  the  mouth, 
called  faucial  tonsils.  By  means  of  a  reflecting 
mirror  placed  in  the  back  of  the  mouth,  looking 
upward  into  the  cavity  above  the  hanging  palate, 
behind  the  nasal  passages,  situated  at  the  roof  of 
the  cavity,  another  tonsil,  called  the  pharyngeal, 
may  sometimes  be  seen.  When  the  pharyngeal 
tonsil  swells,  the  untutored  change  its  name  and 
call  it  ''adenoids."  A  mischievous  misnomer, 
highly  improper,  wonderfully  confusing. 

In  the  back  of  the  mouth  and  in  the  cavity  be- 
hind the  nasal  passages,  there  is  a  peculiar,  elabo- 
rate and  important  arrangement  of  adenoid 
bodies,  known  by  the  name  of  Waldeyer's  lym- 
phatic ring,  which  is  composed  of  six  tonsils — 
the  pharyngeal,  two  faucial,  lingual  (located  on 
the  back  of  the  tongue),  two  tubal  (located  at 
the  mouths  of  the  Eustachian  tubes,  in  the  cavity 
behind  the  nasal  passages),  with  a  secondary 
supporting  formation  consisting  of  numerous 
nodes  and  nodules.  The  bodies  composing  the 
ring  are  connected  by  lymphatic  vessels,  and  com- 
municate with  one  another.  Adenoids  are  so 
placed  in  the  course  of  the  lymphatic  vessels,  that 
the  lymph  in  flowing  toward  the  large  central 


88  THE    TONSILS    AND    THE    VOICE 

trunks^  passes  through  them,  undergoing  a  sort 
of  filtration  as  it  percolates  through  the  partition 
walls  of  the  lymph  passages.  Germs  and  other 
deleterious  matter  which  in  any  way  get  into  the 
lymphatic  vessels  are  carried  along  until  an  ade- 
noid is  reached,  and  here  they  are  deposited  and 
destroyed  by  the  lymph  cells,  while  the  lymph 
itself  passes  on.  Adenoids  are  set  like  sentinels 
to  guard  the  lymphatic  channels  against  invasion. 
Adenoids  are  filters.  When  engaged  in  the 
active  process  of  filtration,  they  always  swell. 
The  swelling  is  in  direct  proportion  to  the  protec- 
tive requirement.  There  is  no  other  cause  for 
their  enlargement  than  augmented  function. 
The  doctrine  that  they  are  filters  is  taught  by 
Delafield  and  Prudden  {New  York) ,  Adami  and 
Nicholls  (Montreal),  and  other  leading  au- 
thorities of  to-day.  In  the  process  of  filtration, 
when  germs  and  other  poisonous  matters  have 
entered  the  adenoid,  their  presence  in  this  body 
stimulates  its  activity  and  leads  to  a  rapid  in- 
crease in  the  number  of  lymph  cells,  lymphocytes, 
leucocytes,  and  phagocytes,  the  duty  of  which  is 
to  attack,  neutralize  or  nullify  the  invadiiig  sub- 
stance. Adenoids  are  readily  eoccited  by  the 
mildest  invasion.  Nature  is  ever  alert  to  protect 
herself.  A  good  illustration  of  the  filter  and  pro- 
tective action  of  adenoids  is  to  be  seen  in  the  case 
of  a  cold  in  the  head.  When  the  lining  of  the 
nose  is  bathed  in  a  secretion  of  mucus  and  pus, 
the  faucial  tonsils  swell  and  are  painful.  The 
f  aucial  tonsil  acts  as  a  filter,  as  a  barrier,  to  the 
foul  secretions  of  the  nose.  This  statement  has 
been  made  by  B.  Frdnkel   (Berlin),  and  con- 


ADENOIDS  89 

firmed  by  Von  Levinstein,  Von  Lendrt  and  other 
authorities.  Adenoids  always  swell  when  active- 
ly engaged  in  the  process  of  filtration. 

"Adenoids,"  "adenoid  vegetations,"  "pharyn- 
geal adenoids,"  "epipharyngeal  tonsil,"  are  dif- 
ferent names  for  the  pharyngeal  tonsil.  The 
pharyngeal  tonsil  is  attached  to  the  roof  of  the 
post-nasal  cavity,  above  the  palate,  and  behind 
the  nasal  passages.  It  is  the  first  lymphatic  organ 
in  the  line  of  exposure  to  invading  germs  by  way 
of  the  nose.  As  the  most  advanced  outpost,  or 
sentry-box  full  of  lymph  cells,  which  increase 
rapidly  in  their  number  upon  the  slightest  alarm, 
it  bears  the  brunt  of  every  battle,  when  germs  are 
attempting  to  invade  the  system  by  way  of  the 
nose.  It  is  the  most  important  organ  of  Wal- 
deyer^s  ring  and  is  considered  by  Frdnkel  as  the 
most  important  protective  organ  of  the  entire 
human  organis^n. 

W estenhoeff er  {Berlin),  by  the  most  exhaus- 
tive investigation,  has  proven  conclusively  that 
the  germs  of  the  cerebrospinal  meningitis  find 
entrance  to  the  general  system  through  the  nose 
and  by  way  of  the  pharyngeal  tonsil.  The  in- 
vasion of  the  system  takes  place,  Westenhoeffer 
states,  only  after  the  protective  influence  of  the 
tonsil  has  been  broken  down  by  great  number 
and  virulency  of  the  invading  germs.  In  the  ex- 
ercise of  its  protective  function,  the  organ  always 
swells,  and  sometimes  attains  a  very  large  size. 
Its  enlargement  is  always  in  direct  proportion  to 
the  protective  requirement.  There  is  no  other 
reason  for  its  enlargement  than  augmented 
function.    The  protective  action  of  the  adenoids 


90  THE    TOXSILS    AND    THE    VOICE 

is  advocated  by  Goerke  and  Brieger,  (Breslau), 
Metchnikoff  (Paris),  and  by  all  the  most  dis- 
tinguished living  authorities. 

A  very  clear  demonstration  of  the  filter  action 
of  adenoids  is  observed  in  the  case  of  nasal 
catarrh,  acute  or  chronic,  in  which  the  Uning  of 
the  nose  is  swollen,  and  covered  with  irritating 
mucus,  and  in  which  also  the  faucial  tonsils  in 
the  back  of  the  mouth  become  swollen  and  pain- 
ful. In  almost  every  instance  of  abrasion  of  the 
nasal  lining,  these  same  adenoids  become  swollen, 
tender  and  painful.  Thorough  cleansing  of  the 
nose  will  cause  prompt  subsidence  of  the  tonsillar 
swelling  and  pain.  This  direct  filtration  and  pro- 
tective action  of  the  faucial  tonsils,  in  case  of  the 
abrasion  of  the  nasal  lining,  is  taught  by  so  great 
an  authority  as  Frdnkel  of  Berlin,  and  is  en- 
dorsed by  Von  Levinstein,  Von  Lendrt  and  others. 
The  2)7'otective  action  of  adenoids  is  also  advo- 
cated by  Brieger,  Goerke  and  Haymann  of 
Breslau,  Metchnikoff  of  Paris,  Delafield  and 
Prudden  of  New  York,  Adami  of  Montreal, 
and  others. 

Popular  medical  writers  advocate  the  com- 
plete removal  of  "adenoids"  as  the  only  appro- 
priate remedy  for  all  the  symptoms  which  they 
allege  "adenoids"  occasion.  They  say  "adenoids 
cause"  and  "The  operation  cures,  frog  face,  bow 
legs,  pigeon  breast,  club  feet,  irregular  jaw, 
twisted  teeth,  short  thick  upper  Hp,  narrow  nos- 
trils, open  mouth,  expressionless  and  undeveloped 
face,  misshaped  nose,  nasal  catarrh,  impaired 
smell,  laryngitis,  spasm  of  the  larynx,  false  croup, 
cough,  hoarseness,  defective  speech,  stammering 


ADENOIDS  91 

and  stuttering,  inflammation  of  the  eyes,  defec- 
tive eyesight,  misshaped  ear  drums,  inflammation 
of  the  ears,  plugged  Eustachian  tubes,  mastoid 
disease,  deafness,  impaired  taste,  bad  breath,  dis- 
ordered stomach  and  bowels,  constipation,  bilious- 
ness, weak  bladder,  incontinence  of  urine,  bad 
dreams,  snoring,  grinding  of  the  teeth,  disturbed 
sleep,  daytime  restlessness,  depression  of  spirits, 
lack  of  energy,  stupidity,  headache,  listlessness, 
backwardness  in  study,  retarded  and  impaired 
mental  faculties,  stunted  growth  of  body,  parox- 
ysmal sneezing,  hay  fever,  asthma,  bronchial 
affections,  lung  diseases,  nervous  diseases, 
epilepsy,  St.  Vitus'  dance,  wry  neck,"  etc.  Each 
and  all  of  the  symptoms  above  mentioned  are 
quoted  from  standard  text-books. 

This  remarkable  indictment  of  a  swollen 
pharyngeal  tonsil,  the  so-called  "adenoids,"  is 
apt  to  stagger  good  judgment,  and  constantly 
demands  the  greatest  skill  in  deternwiing  the 
precise  conditions  that  eocist  in  each  and  every 
instance.  The  full  measure  of  value  possessed 
by  the  art  of  diagnosis,  by  that  art  the  knowledge 
of  which  leads  to  the  determination  of  a  disease 
by  means  of  distinctive  marks  or  signs,  is  always 
demanded  wherever  "adenoids"  are  suspected. 
The  art  of  diagnosis  is  difficult.  Experts  in  the 
art  are  few.  The  art  exacts  a  profound  knowl- 
edge of  diseased  conditions,  and  of  their  relation- 
ship to  one  another.  To  become  an  expert  diag- 
nostician requires  great  experience. 

A  correct  diagnosis  will  clear  the  field  of  most 
of  the  terrors  that  surround  cases  of  supposed 
''adenoids."     A  positive  opinion  can  not  be  safely 


92  THE    TONSILS    AND    THE    VOICE 

based  on  "suspicious"  circumstances.  ''Adenoids" 
may  exist  without  causing  any  symptoms. 
Symptoms  may  be  present  without  ''adenoids." 
"The  open  mouth,  frog  face,  stupidity,  back- 
wardness and  slow  mental  and  physical  develop- 
ment" are  not  always  due  to  an  enlarged  pharyn- 
geal tonsil.  Far  from  it.  Ninety-five  per  cent 
of  the  so-called  "adenoids,"  judged  by  the  open 
mouth  alone,  are  mistakes  in  diagnosis.  Neither 
does  the  pharyngeal  tonsil,  when  enlarged,  the 
so-called  "adenoids,"  appear  as  a  soft  jelly-like 
mass,  bathed  in  a  blanket  of  mucous  secretion; 
but,  upon  the  contrary,  it  is  as  firm  and  as  hard  as 
an  enlarged  faucial  tonsil. 

Friedrich  {Rhinology,  Laryngology  and  Oto- 
logy in  General  Medicine)  : 

"Any  and  all  diseases  of  the  nose  and  post- 
nasal space  which  are  followed  by  obstruction  of 
the  nasal  passages  lead  to  passive  hyperaemia  in 
the  mucous  membranes,  which  in  turn  produces 
occlusion  of  the  Eustachian  canal.  The  recogni- 
tion of  this  important  fact  is  comparatively  re- 
cent." 

"The  interference  with  nasal  breathing  may  be 
due  to  a  number  of  conditions  within  the  nose,  as 
hypertrophy  of  the  mucous  membrane,  mucous 
polypi,  tumors,  foreign  bodies,  etc." 

"If  I  have  included  hypertrophy  of  the  pharyn- 
geal tonsil  or  adenoid  vegetations  among  the 
diseases  which  produce  hyperaemia  and  swelling 
of  the  mucous  membrane  with  occlusion  of  the 
tube,  by  interfering  with  nasal  respiration,  it  is 
because  I  believe  the  occlusion  is  due  to  a  general 
'adenoid  habit'  of  the  nose  and  pharynx,  rather 


ADENOIDS  93 

than  to  the  direct  mechanical  intrusion  of  the 
pharyngeal  tonsil." 

"Two  forms  of  adenoid  enlargement  are  dis- 
tinguished: a  diffuse,  cushion-hke  hyperplasia, 
and  a  villous  variety  consisting  of  the  finger-like 
projections  or  true  vegetations." 

"As  the  vegetations  usually  spring  from  the 
median  line,  they  are  not,  when  at  rest,  in  contact 
with  the  lateral  walls  of  the  pharynx,  and  there- 
fore do  not  occlude  the  orifices,  as  we  are  fre- 
quently able  to  demonstrate  in  the  post-rhino- 
scopic  image." 

"The  adenoid  tissue  is  not  the  soft,  gelatinous 
mass  that  it  is  sometimes  compared  to,  but  is 
comparatively  firm,  and  returns  to  its  normal 
position  of  rest,  dependent  on  gravity,  as  soon  as 
the  constriction  of  the  pharynx  and  the  tensores 
and  levatores  palati  relax  and  the  post-nasal 
cavity  regains  its  normal  volume.  But  it  is  not 
clear  to  me  how  a  momentary  occlusion  of  the 
orifice  can  have  the  same  effect  as  a  permanent 
one,  and  I  therefore  consider  the  hyperaemia  of 
the  entire  mucous  membrane  the  most  important 
factor  in  the  production  of  aural  complications." 

"Paralysis  of  the  muscles  of  the  soft  palate, 
especially  of  the  levator  veli  palatini  and  tensor 
veli  palatini — muscles  which  effect  the  opening 
of  the  Eustachian  tube — ^is  followed  by  perma- 
nent occlusion  with  the  usual  appearances  of  the 
membrana  tympani.  The  action  of  the  muscles 
may  be  similarly  affected  by  tumors,  tubercular 
ulcerations,  or  their  scars,  and  by  cleft  palate,  so 
that  these  conditions  are  also  occasionally  ac- 
companied by  middle-ear  disease." 


94  THE    TONSILS    AND    THE    VOICE 

There  are  two  ways  by  which  to  prove  the  pres- 
ence of  ''adenoids."  They  must  he  seen.  They 
must  he  felt.  They  may  be  seen  by  reflection  in 
a  mirror,  placed  in  the  back  of  the  mouth,  looking" 
upward  into  the  cavity  behind  the  hanging  palate. 
They  can  sometimes  be  seen  by  looking"  through 
the  nostrils.  They  can  be  felt  by  the  finger  in- 
troduced into  the  mouth  and  pushed  up  behind 
the  hanging  palate.  Sight  and  touch  alone  can 
determine  the  presence  of  ''adenoids'*  Is  it  easy 
to  see  "adenoids"  in  the  glass  or  through  the 
nostrils?  No.  It  is  most  often  impossible.  Is 
it  easy  to  introduce  the  finger  behind  the  hanging 
palate  ?  Not  always.  Sometimes  it  is  impossible. 
And  it  is  always  unwise  to  try  to  introduce  a 
large  finger.  The  precise  facial  expression  of 
"adenoids"  may  be  simulated  by  any  nasal  ob- 
struction. There  may  be  very  great  enlargement 
of  the  pharyngeal  tonsil  without  the  typical  facial 
expression.  Natier  insists  that  in  some  neurotic 
children  a  state  of  "false  adenoidism"  exists. 
W.  Braden  Kyle  (Philadelphia,  1907),  remarks: 
"The  symptoms  of  adenoid  vegetations  are  very 
much  the  same  as  those  found  in  any  nasal  or 
post-nasal  obstruction.  I  have  seen  many  cases  of 
post-nasal  obstruction  in  children  which  on  ex- 
amination would  seem  to  indicate  immediate  sur- 
gical interference,  in  which  complete  relief  was 
obtained  by  the  correction  of  intestinal  irregulari- 
ties, such  as  obstruction,  constipation,  or  irrita- 
tion produced  by  intestinal  worms,  there  will  re- 
sult turgescence  with  watery  infiltration  of  the 
nasal  and  post-nasal  structures.  The  pharyngeal 
tonsil  in  childhood  is  a  normal  structure,  and  its 


ADENOIDS  95 

enlargement  as  described  above  is  frequently- 
mistaken,  for  an  increase  in  cellular  elements 
when  in  reality  it  is  only  the  normal  structure 
enlarged  by  fluid  distention." 

Lejinox  Browne  (London)  states:  "The  post- 
nasal space  may  be  blocked  l3y  polypi,  cysts,  and 
hypertrophied  turbinals  or  by  fibrous  and  malig- 
nant tumors.  But  by  far  the  most  common  af- 
fection is  enlargement  of  the  pharyngeal  tonsil 
called  'adenoids,'  'growths'  or  'post-nasal  vegeta- 
tions.' The  'vegetations'  are  not  new  growths 
but  merely  outgrowths  of  the  normal  tissue  of 
the  region." 

Sir  Felix  Semon  {Lo7ido7i,  1902)  says:  "Lym- 
phoid tissue  being  very  vascular  easity  becomes 
the  seat  of  catarrhal  inflammation,  when  it  swells 
considerabty,  and  pro  tem,  may  present  all  the 
symptoms  of  'adenoids.'  I  am  a  great  skeptic 
with  regard  to  reflex  neuroses  arising  from  the 
upper  air  passages  in  general,  and  particularly 
so,  with  regard  to  those  said  to  be  due  to  'aden- 
oids.' Let  me  warn  you  against  too  hastily 
diagnosing  'adenoids'  from  facial  appearance 
and  nasal  obstruction  alone." 

Mar  age  (Paris):  "Divides  patients  suffering 
from  adenoid  tumors  into  three  classes:  (1st) 
Those  who  have  hard  and  large  tumors;  they  pre- 
sent generally  very  serious  complications  either 
affecting  respiration  and  its  development,  or  by 
affecting  the  hearing.  (2nd)  In  the  second 
class  we  arrange  the  patients  in  whom  the 
growths  are  soft,  large  and  bleed  readily  under 
the  pressure  of  the  finger;  there  is  a  cessation  of 
development  of  the  patient,  a  deafness  more  or 


96  THE    TONSILS    AND    THE    VOICE 

less  persistent,  an  inaptitude  for  work.  (3rd) 
The  third  class  comprises  those  who  with  the 
growths  hut  little  developed  present  in  general 
only  the  following  symptoms,  intermittent  deaf- 
ness, mouth  partly  open,  snoring  at  night.  Hos- 
pital patients  are  almost  all  comprised  in  the  first 
category." 

"Adenoids"  is  not  a  fatal  disease.  Not  one 
death  from  this  cause  has  ever  been  reported. 
But  thousands  of  deaths  have  occurred  from  the 
operation  for  their  removal.  The  operation  is 
always  bloody,,  always  painful^  always  dan- 
gerous. 

The  most  eminent  operators  in  the  world  have 
reported  deaths  from  operations,  the  list  inclu- 
ding such  skilful  technicians  as  Lennox  Browne, 
Mayo-Collier,  Schniiegelow,  Damianos  and  Her- 
mann, Sandfort,  Marage,  Escat,  Delavan, 
Burger,  Schuchardt,  Stucky,  Sachs,  Prehle, 
Putnam,  Barhan,  Hooper,  Bliss,  Kenefich, 
Stewart,  Newcomh,  Thompson,  Goldsmith  and 
others. 

When  these  most  experienced  and  skilful 
operators  report  deaths,  then  what  of  those  with 
lesser  experience  and  lesser  skill? 

The  operation  for  the  removal  of  "adenoids" 
is  followed  by  the  most  appalling  list  of  accidents 
of  any  operation  in  the  history  of  surgery. 

Serious  accidents  have  been  reported  by  such 
distinguished  operators  as,  Gronbeck,  Tilley, 
Castex,  Coley,  Browne,  Win  grave.  Riviere, 
Hagedorn,  Broeckhaert,  Holmes,  Lunin,  Her- 
mann, Mygind,  Thurly,  Quinlan,  Hope,  Citcelli, 
Hennebert,  Chappell,  Weber,  Woeblews,  Bulso, 


ADENOIDS  97 

Urban,  Cline,  Kan,  Thomas,  Ryan,  Wilkinson, 
Nettlehrock,  Avale,  Henking,  Henkes,  Cun- 
ninghani,  Cliapnian  and  others.  ^ 

Among  the  accidents  reported  as  following 
the  operation  are:  "Death  from  hemorrhage,  im- 
mediate or  secondary;  recurrent  hemorrhage; 
asphyxia,  mental  disturbance;  laceration  of 
lining  membrane  of  post-nasal  cavity;  injury  of 
the  nasal  septum;  recurrent  nasal  hemorrhages; 
permanent  derangement  of  blood  circulation  in 
the  nose;  permanent  redness  of  the  nose;  injury 
and  laceration  of  the  palate,  palatine  muscles  and 
of  the  uvula;  paralysis  of  the  velum  of  the  pal- 
ate; injury  of  the  Eustachian  tubes;  acute  in- 
flammation of  the  post-nasal  region;  inflamma- 
tion of  the  nasal  lining  membrane;  infection  of 
the  wound;  abscess;  diphtheria  of  the  wound; 
blood  poisoning;  scarlet  rash;  cerebral  menin- 
gitis; arthritis;  tonsillitis;  laryngitis;  inflamma- 
tion of  Eustachian  tubes;  ear  disease;  mastoid 
disease ;  rupture  of  ear  drums ;  running  ears ;  ear- 
ache; deafness;  inflammation  of  the  eyes;  dis- 
turbance of  vision ;  alteration  and  impairment  of 
the  voice;  removal  of  the  first  important  line  of 
defense  against  germ  infection;  awakening  of 
latent  diseases;  development  of  sarcoma  (can- 
cer) ;  development  of  latent  tuberculosis  in  adja- 
cent glands  and  in  the  lungs;  neuralgia;  head- 
ache; vertigo;  syncope  (faintness)  ;  general  ner- 
vousness; spasm  of  the  larynx;  asthma;  goitre; 
Basedow's  disease;  profound  anaemia,  loss  of 
general  health  and  strength;  troublesome  con- 
traction of  wound;  troublesome  scars,  return  of^ 
'adenoids,'  "  etc. 


98  THE    TONSILS    AND    THE    VOICE 

It  is  impossible  to  completely  remove  adenoid 
tissues.  This  statement  is  made  by  Groher  of 
Vienna,  Von  Levinstein  of  Berlin,  Goerke 
and  Brieger  of  Breslau,  Marage  of  Paris,  and 
others. 

Adenoids  grow  again  after  they  have  been  re- 
moved. This  is  the  teaching  of  Goerke,  Von 
Levinstein  and  others.  The  same  causes  which 
led  to  the  first  growth  lead  to  a  new  growth. 

Adenoids  disappear  spontaneously.  This 
statement  is  made  by  Escat  (Toulouse),  Bos- 
worth  (New  York),  Grayson  (Philadelphia) 
and  all  other  authorities.  "Adenoids,"  or  to 
speak  properly,  enlargement  of  the  pharyngeal 
tonsil,  is  not  so  common  as  the  doctors  say,  or  as 
the  public  imagines.  From  reports  courteously 
sent  to  me  by  S.  Josephine  Baker,  M.D.,  of  the 
Department  of  Health,  New  York  City;  the  Re- 
port of  the  Department  of  Health  of  Chicago; 
Oliver  P.  Coonan,  the  Board  of  Public  Educa- 
tion of  Philadelphia;  George  P.  Barth,  M.D., 
Public  Schools  Medical  Inspection,  Milwaukee; 
the  Superintendent  of  Instruction  of  Public 
Schools,  St.  Louis;  H.  B.  Burns,  M.D.,  Depart- 
ment of  Public  Health,  Pittsburgh;  Chas.  H. 
Keene,  M.D.,  Department  of  Public  Schools  of 
Minneapolis;  the  Annual  Report  of  the  Depart- 
ment of  Public  Health,  San  Francisco,  I  have 
made  the  following  collaboration  of  the  whole 
number  of  pupils  examined,  of  the  number  that 
had  enlarged  adenoids,  and  of  the  number  that 
had  enlarged  tonsils. 


ADENOIDS 


99 


Number 
Examined 

Nuniber  with 
enlarged 
adenoids 

Number  with 

enlarged 

tonsils 

New  York  City,  1910.... 

Chicago,  1910 

Philadelphia,  1911 

Milwaukee,  1910-1911    . . 
St.  Louis,  1910-1911  .... 

Pittsburgh,  1911    

Minneapolis,  1911 

San  Francisco,  1909-1910 

266,426 

126,847 

25,000 

19,616 

16,788 

12,704 

7,102 

2,207 

40,946 

4,702 

852 

506 

204 

1,324 

2,042 

173 

50,012 

24,286 

714 

3,834 

952 

2,322 

2,474 

409 

476,690 

50,049 

85,003 

The  table  shows  that  less  than  one  in  nine  of 
the  whole  number  eccamined  had  enlarged  aden- 
oids.   Less  than  one  in  five  had  enlarged  tonsils. 

In  the  Eleventh  Annual  Report  of  the  City 
Superintendent,  New  York  City,  1909,  there  is 
an  article  on  ''The  Relation  of  Physical  Defects 
to  School  Progress/'  by  Leonard  P.  Ay  res,  in 
which  it  is  stated  that  "a  careful  tabulation  was 
made  of  the  records  of  physical  examinations  of 
7,698  children  who  had  been  examined  by  school 
physicians.  Nearly  80  per  cent  of  the  children 
who  were  of  normal  age  for  their  grades  were 
found  to  have  physical  defects,  while  only  about 
75  per  cent  of  the  retarded  children  were  defec- 
tive. The  percentage  of  defective  children  in  the 
lower  grades  was  decidedly  greater  than  in  the 
upper  grades.  Retarded  children  will  be  older  than 
their  fellow  pupils  in  the  same  grade.  In  all  cases 
it  will  always  be  true  that  the  backward  pupils 
will  be  the  older  pupils.  Now,  the  older  pupils 
are  found  to  have  fewer  defects.  This  is  true 
whether  they  are  behind  their  grades  or  well  up 


100  THE    TONSILS    AND    THE    VOICE 

in  their  studies.  Eighty  per  cent  of  all  children  of 
normal  age  have  physical  defects  more  or  less 
serious,  wJiile  75  per  cent  of  the  retarded  children 
are  found  to  he  defective.  About  one  child  in 
every  four  has  hypertrophied  (enlarged)  tonsils. 
About  one  child  in  eight  has  adenoids.  The 
figures  do  not  really  show  the  retarding  influence 
of  each  sort  of  defect  separately  for  the  reason 
that  the  same  child  is  often  suffering  from  sev- 
eral sorts  of  defects." 

In  a  pamphlet  on  ''What  American  Cities  are 
Doing  for  the  Health  of  School  Children''  pub- 
lished by  the  Russell  Sage  Foundation  of  New 
York,  covering  a  report  of  1038  cities,  it  is  stated 
that  "medical  inspection  of  the  public  schools  is 
for  the  purpose  and  to  best  enable  the  child  to 
take  full  advantage  of  the  free  education  offered 
by  the  state.  Let  us  have  good  men  to  do  the 
work  and  let  us  pay  them  well.  It  will  demand  a 
special  training  and  a  careful  technique.  It  is 
certainly  to  be  regretted  that  this  point  of  view 
has  not  been  more  generally  taken  in  America.'' 

The  fact  is  notorious  that  the  medical  inspec- 
tion of  the  public  schools,  as  a  rule,  is  made  by  the 
very  youngest  and  least  experienced  physicians. 
Politics  and  inexperienced  physicians  will  en- 
danger the  entire  system  of  inspection. 

The  Russell  Sage  Foundation  Report  states 
that  "There  are  75  cities  in  which  doctors  donate 
their  services.  The  average  salary  paid  to  doctors 
falls  within  from  $200  to  $300  per  annum.  Two 
hundred  dollars  per  annum  has  come  to  be  re- 
garded as  a  somewhat  standard  rate  of  remuner- 
ation for  school  physicians  all  over  the  United 


ADENOIDS 


101 


States f'  The  following  table  gives  a  partial  list 
of  cities  taken  from  the  Report  of  population  and 
the  number  of  doctors  employed  by  each  city. 


Population 

Doctors 
Employed 

4,763,883 

142 

2,185,283 

100 

1,549,008 

30 

687,029 

6 

533,905 

30 

416,912 

1 

373,857 

10 

301,408 

7 

New  York  City 
Chicago      .... 
Philadelphia  .  . 

St.  Louis 

Pittsburgh    .  .  . 
San  Francisco 
Milwaukee  .  .  . 
Minneapolis  .  . 


In  the  City  of  Pittsburgh,  the  school  doctors 
receive  one  hundred  dollars  per  month.  And 
there  are  just  as  many  school  doctors  in  this  City 
as  in  Philadelphia,  which  has  three  times  the  pop- 
ulation of  Pittsburgh.  The  question  becomes 
pertinent,  Does  Pittsburgh  receive  three  times 
more  efficient  service  than  Philadelphia?  And  at 
five  times  more  cost  than  the  average  inspection 
throughout  the  United  States  ?  Does  Pittsburgh 
receive  more  than  thirty  times  the  efficiency  of 
San  Francisco?  By  what  gauge  may  the  marked 
discrepancies  be  explained  and  may  efficiency  be 
best  judged,  or,  is  the  whole  situation  at  present 
really  one  of  politics  and  graft? 

Inspection  and  inquisition  are  sometimes 
coupled  in  the  Pittsburgh  schools.  What  doctor 
attends  your  children?  is  sometimes  asked  of  the 
parents.  Sometimes  parents  are  told  to  take 
their  children  to  certain  doctors  whom  the  in- 


102  THE    TOXSILS    AND    THE    VOICE 

spector  designates  for  operation.  And  sometimes 
particular  hospitals  are  favored. 

In  a  paper  read  before  the  Society  of  Medical 
Inspectors  of  the  City  of  New  York,  December 
4,  1908,  Dr.  Neustaedter  stated: 

"Much  stress  has  been  laid  upon  such  physical 
defects  as  enlarged  tonsils,  adenoids,  refractive 
errors,  and  carious  teeth,  as  the  most  prominent 
causative  factors  in  backward  children.  But 
when  we  surs^ey  the  statistics  and  find  85  per  cent 
of  all  school  children  are  suffering  from  some 
physical  ailment,  and  among  the  sufferers  96 
per  cent  are  bright  pupils,  and  on  the  other  hand 
some  of  the  most  vicious  children  whom  I  have 
personally  examined  pl*esented  no  physical  de- 
fects that  I  w^as  able  to  detect,  it  seems  to  me 
imperative  that  we  look  further  than  tonsils  and 
adenoids."  He  mentions  drug  habits,  bad  food, 
impure  air.  Under  date  of  April  25,  1911,  he 
continues:  "Among  8,000  pupils,  10  per  cent 
of  all  are  the  very  best,  and  about  10  per  cent 
are  backward.  Tonsils  are  slightly  more  preva- 
lent in  the  best  pupils.  The  best  singers  have 
50  per  cent  more  tonsils  than  the  poorest.  I  have 
yet  to  see  the  backward  pupil  who  became  pro- 
ficient after  removal  of  tonsils,  provided  other 
factors  were  not  ameliorated.  Six  hundred 
backward  pupils  who  had  their  diet  and  mode  of 
life  changed,  and  of  whom  only  two  per  cent  had 
corrected  physical  defects  gave  good  results, 
namely:  98  per  cent  did  good  work  after  six 
months." 

William  L.  Bodine,  president  of  the  National 
League  of  Compulsory  Education,  in  his  annual 


ADENOIDS  103 

address  to  that  body,  said:  "The  underfed  child 
means  the  backward  pupil  at  school,  and  the 
backward  pupil  means  truancy,  or  delinquency. 
Poverty  is  the  great  cause  of  truancy  and  irregu- 
lar attendance.  The  higher  the  cost  of  living  the 
lower  the  chances  of  the  children  of  the  poor  to 
complete  the  eighth  grade." 

Being  under-fed  is  a  good  reason  for  a  pupil 
being  backward.  No  one  should  expect  a  hun- 
gry child  to  make  a  bright  pupil.  But,  at  the 
same  time  that  a  charitable  public  furnishes  milk 
and  sandwiches  to  under-fed  children  upon  their 
arrival  at  school  in  the  morning,  it  is  not  consis- 
tent for  the  school  doctor,  when  he  arrives,  to 
take  out  their  tonsils  and  "adenoids"  upon  the 
ground  that  they  are  backward  pupils. 

Remarkable  improvement  has  been  noted  in 
mentally  and  physically  backward  children  fol- 
lowing the  administration  of  thyroid  extract. 

The  operation  for  "adenoids"  should  never  be 
undertaken  without  serious  consideration.  It  is 
often  very  difficult.  It  is  always  bloody;  always 
painfid  and  often  fatal.  The  operation  shoidd 
never  be  perforined  in  cases  that  cause  no  symp- 
toms; never  in  patients  who  are  known  as  bleed- 
ers. The  results  of  operation  will  always  be  dis- 
appointing in  cases  that  accompany  nasal  ca- 
tarrh; with  thickening  of  the  lining  of  the  nasal 
passages;  in  cases  of  iiarrow  nostrils,  and  mis- 
shaped nose;  in  cases  of  irregular  teeth;  in  de- 
formity of  the  upper  jaw;  in  deformity  of  the 
mouth  and  palate;  in  cases  of  deafness,  with  in- 
flammation of  the  middle  ear  and  with  thickening 
and  hardening  of  the  lining's  of  the  ear  passages; 


104  THE    TONSILS    AND    THE    VOICE 

in  affections  of  the  ear  drum;  and  in  all  children 
with  poor  constitutions,  improper  or  insufficient 
food,  and  had  hygienic  surroundings. 

Normal  adenoid  tissues  should  always  he  pre- 
served if  possible.  In  the  strictest  concordance 
with  the  very  latest  teachings  of  the  very 
latest  and  best  authorities,  namety:  (1)  of 
Delafieldj  Prudden,  Adami  and  others  that 
adenoid  bodies  of  all  sizes,  whether  called 
nodules,  nodes  or  tonsils,  are  filters;  (2)  of  Brie- 
ger,  Goerhe,  Frdnkel,  Metchnikoff,  and  others 
that  they  protect  the  human  system  against  the 
invasion  of  germs;  (3)  of  Groher,  Escat,  Goerke, 
Mackenzie,  Von  Levinstein  and  others  that  they 
cannot  he  completely  removed  hy  a  surgical 
operation;  (4)  of  Goerke,  Brieger,  Von  Levin- 
stein, Escat,  Wright,  Grayson  and  others  that 
when  removed  they  grow  again;  (5)  of  Escat, 
Bosworth  and  others  that  they  disappear  spon- 
taneousty;  (6)  of  Mackenzie,  Semon  and  others, 
that  the  operation  for  their  removal  is  greatly 
ahused  hy  its  ignorant  and  reckless  mis-applica- 
tion to  unsuitable  cases;  (7)  of  the  fact  that  the 
operation  is  followed  by  numerous  deaths;  (8) 
of  the  fact  that  the  operation  is  always  bloody, 
always  painftd,  and  is  followed  by  the  most  ap- 
palling list  of  accidents  that  ever  followed  any 
surgical  measure;  (9)  of  the  fact  that  92  per  cent 
of  all  cases  can  he  cured  without  operation,  as 
proved  hy  Marage  and  others,  I  desire  to  ask. 
Is  it  not  reasonable  to  demand  that  greater  re- 
strictions he  imposed  upon  operations  for  the  re- 
moval of  ''adenoids'';  that  greater  efforts  be 
made  to  improve  the  hygienic,  pthysiologic  and 


ADENOIDS  -     105 

sanitary  conditions  of  the  patient;  to  better  the 
ventilation  of  the  sleeping  apartments;  to  better 
the  quality  and  quantity  of  food  and  to  regulate 
outdoor  eocercise;  to  thoroughly  cleanse  and  keep 
sterilized  the  nasal  passages;  and  to  adopt  the 
newer  lines  of  treatment,  safer  and  more  in  ac- 
cord with  the  modern  research  of  Lendrt  and 
Poli  and  the  therapy  of  Von  Levinstein,  Frdnkel, 
Brieger,  Goerke,  Chiari,  Marage,  Escat,  Moure, 
Jacobi  and  other  high  authorities? 


CHAPTER  VII 
THE  TONSILS  AND  THE  TEETH. 

The  functional  relationship  between  the  teeth 
and  tonsils  is  interesting.  George  H.  Wright, 
in  an  elaborate  article  in  the  Boston  Medical  and 
Surgical  Journal,  May  20,  1909,  gives  a  detailed 
account  of  his  views  regarding  this  relationship, 
and  draws  "attention  to  four  periods  in  the  de- 
velopment of  an  individual  from  two  to  eighteen 
years,  when  the  tonsils  become  slightly  enlarged 
without  inflammation  and  without  obstruction  or 
evidence  of  suppuration,  and  these  four  periods 
are  represented  practically  at  the  time  when  four 
groups  of  molars  are  in  the  process  of  eruption. 
That  is,  the  periods  with  slight  variation  are 
from  two  years  for  the  first  group;  six  years  of 
age,  the  second  group;  twelve  years,  the  third 
group;  and  from  seventeen,  the  fourth  group. 

"I  propose  to  show  that  these  enlargements  of 
tonsils  coincide  definitely  with  these  particular 
periods  of  tooth  eruption.  I  hope  to  show,  too, 
that  when  there  is  no  infection  of  the  tonsil,  by 
keeping  the  patient  under  observation  and  giv- 
ing, if  necessary,  simple  prophylactic  treatment 
to  the  tonsil  and  waiting  for  the  normal  eruption 
of  the  tooth,  even  the  slight  hyperaemia  of  the 
tonsil,  which  is  its  expression  of  function,  will 
entirely  disappear  and  the  tonsil  will  return  to  its 
normal  condition. 

"We  offer  for  consideration  nineteen  patients, 
and  in  each  case  the  enlargement  coincided  with 

106 


THE    TONSILS    AND    THE    TEETH  107 

the  second,  third  or  fourth  periods  of  tooth  erup- 
tion. In  no  instance  did  we  find  excessive  en- 
largement or  suppuration.  Yet  all  these  pa- 
tients were  sent  to  us  by  physicians  and  social 
seiTice  workers,  or  they  came  on  their  own  initia- 
tive for  treatment  and  operation.  None  have 
been  operated  on  for  removal  of  the  tonsils.  In 
two  patients  under  observation  since  last  May, 
the  tonsils  have  returned  to  normal  and  the  teeth 
are  fully  erupted. 

"Another  aspect  of  the  problem  is  illustrated 
by  a  boy,  age  eleven,  who  had  his  tonsils  extir- 
pated three  years  ago;  he  came  to  us  for  treat- 
ment for  glandular  enlargements  in  the  neck. 
The  tonsillar  gland  is  markedly  enlarged  and 
other  glands  enlarged  and  distributed  down  to 
the  border  of  the  clavicle.  No  history  of  tuber- 
culosis in  family." 

"We  exhibited  another  patient,  girl,  age  seven- 
teen. Tonsil  slightly  enlarged  on  right.  Left 
tonsil  normal.  Right  tonsil  later  removed. 
Three  months  later  patient  returned  and  shows 
enlarged  tonsillar  gland  the  size  of  a  hen's  egg. 
Examination  of  mouth  reveals  lower  third  molar 
cutting  through  the  gums — the  fourth  period. 
Also  remnant  of  root  of  lower  six  year  molar. 
The  root  was  extracted  and  operation  on  glands 
deferred.  One  month  later  patient  reported. 
We  found  the  gland  reduced  to  normal,  no  pain 
or  swelling  of  any  kind  and ,  tooth  erupted. 
(Since  reporting  these  cases,  January  30,  1909, 
we  now  have  a  record  of  forty-nine  patients 
where  operations  on  tonsils  have  been  deferred, 


108  THE    TONSILS    AND    THE    VOICE 

awaiting  eruption  of  the  molars  in  the  several 
periods. ) 

"With  the  enormous  structural  upbuilding 
where  nature  is  elaborating  the  materials  for 
forty-eight  teeth,  and  the  jaws,  there  is  much 
waste  tissue  to  be  disposed  of.  Sometimes  there 
will  be  a  swelling  in  the  region  of  the  submaxil- 
lary and  lymphoid  enlargements,  intense  pain, 
excessive  salivation,  followed  by  a  hot  and  fever- 
ish condition  of  the  oral  mucous  membrane,  and 
occasionally  a  slight  cough.  The  disturbance 
may  continue  until  we  find  a  slightly  enlarged 
tonsil,  or  even  acute  otitis  media  with  a  sinus  and 
profuse  suppuration  discharge  through  the  ex- 
ternal ear.  Usually  within  a  few  hours  or  days, 
at  least,  the  offending  molar  will  make  its  ap- 
pearance through  the  gum,  disturbance  will 
cease,  and  tonsil  return  to  its  normal  condition. 
So,  too,  in  the  adjacent  region  of  the  upper  first 
and  second  temporary  molars,  we  may  find  lym- 
phatic enlargements  involving  the  parotid  gland, 
lachrymal  gland  and  tonsil.  The  faucial  tonsil 
and  normal  adenoid  upon  the  side  nearest  to  the 
erupting  tooth  may  become  considerably  en- 
larged through  the  influence  of  the  lymphatically 
absorbed  waste. 

"Some  years  ago  we  made  experiments  by  seal- 
ing a  coloring  of  Prussian  blue  into  teeth  pulps 
of  dogs,  to  determine  the  lymphatic  drainage, 
and  it  was  shown  conclusively  that  the  blue  par- 
ticles passed  directly  through  the  pulp  to  the 
lymphatic  glands  and  endothelial  spaces. 

''Wood  states:  'Clinically  the  gland  which  be- 
comes enlarged  during  tonsillar  infection  appears 


THE    TONSILS    AND    THE    TEETH  IQQ 

to  be  superficial  and  has  led  to  the  belief  that  the 
posterior  gland  of  the  submaxillary  groups  is  in- 
fected through  the  tonsils.'  This  may  be  rightly 
so  under  some  conditions,  yet  I  incline  to  the  be- 
lief that  this  particular  gland  which  may  become 
enlarged  at  the  periodic  time  of  teeth  eruption 
and  coincident  enlargement  of  the  tonsil  is  en- 
larged not  because  of  infection  through  the  tonsil 
per  se^  but  through  normal  waste  or  combined 
with  bacteria  from  the  diseased  membranes  adja- 
cent to  erupting  teeth,  and  that  the  enlargement 
of  the  gland  is  due  to  this  latter  process,  and  the 
tonsillar  enlargement  without  infection  is  a  nor- 
mal expression  of  the  active  function  of  the  ton- 
sillar gland,  and  when  the  tonsil  becomes  in- 
fected, it  does  so  because  of  its  lack  of  power  of 
resistance  to  the  invasion  of  micro-organisms. 

''Jonathan  Wright  has  made  a  careful  study  of 
normal  tonsils  in  relation  to  behavior  of  the  epi- 
thelial cell  in  the  crypts  toward  bacteria  and  their 
relation  toward  dust,  with  conclusions  which 
demonstrate  that  pathogenic  bacteria  inhabit  the 
tonsillar  crypts  in  great  numbers,  and  do  not  en- 
ter the  tonsillar  tissue  proper  so  long  as  the  ton- 
sils are  in  a  normal  and  healthy  condition." 

The  author  of  the  latest  text-book  on  the 
"Diseases  of  the  Nose,  Throat  and  Ear,"  has  "at- 
tempted the  complete  removal"  of  2,000  tonsils! 
What  per  cent,  were  examined  in  connection  with 
carious  teeth?  What  per  cent  came  in  the  four 
periods  of  tooth  development?  What  per  cent, 
would  have  been  unnecessary  when  function  of 
tooth  eruption  had  ceased?  What  per  cent,  were 
slightly  enlarged  with  no  mechanical  obstruction 


110  THE   TONSILS    AND    THE    VOICE 

or  abscess?  What  per  cent,  might  have  re- 
sponded to  prophylactic  treatment  and  given  no 
subsequent  trouble?  What  per  cent,  have  or 
will  develop  deeper  troubles  beyond  these  bar- 
riers of  the  lymphoid  ring  of  Waldeyer  because 
it  is  presumable  that  the  adenoid  tissue  was  re- 
moved at  the  same  time  from  the  vault  of  the 
pharynx  ?  What  per  cent,  of  cases  of  temporary 
paresis  of  the  palato-pharyngeus  muscles,  cervi- 
cal cellulitis  and  hemorrhages?  What  per  cent, 
of  lymphoid  enlargements,  both  superficial  and 
deep,  will  occur  later  in  life? 

George  H.  Wright:  "As  to  what  the  tonsil 
may  yield  as  a  by-product  after  the  metamor- 
phoses of  this  normal  waste,  and  what  influence 
the  by-product  as  a  secretion  through  the  crypts 
to  the  digestive  canal  may  have  upon  the  body  as 
a  whole,  is  a  question  for  the  future  to  determine. 

"In  conclusion,  we  offer  these  six  observations: 

(1)  When  a  tonsil  is  normal,  infection  from 
the  external  surface  is  rare. 

(2)  Secondary  infection  through  the  lymph 
channels  is  the  usual  source. 

(3)  There  are  four  periods  of  molar  erup- 
tions, with  some  variations  in  time  when  the  ton- 
sils may  enlarge  without  infection  or  inflamma- 
tion, at  two  years,  six,  twelve  and  seventeen. 

(4)  Tonsils,  when  slightly  enlarged  and  not 
infected,  return  to  normal  with  complete  erup- 
tion of  the  teeth. 

(5)  Diseased  teeth  are  a  prolific  source  of  en- 
largement of  the  glands,  through  proximity  of 
membranes,  either  directly,  by  infection,  or  by 
toxins. 


THE    TONSILS   AND   THE    TEETH  m 

(6)  In  the  treatment  of  the  tonsil  by  the 
specialist,  may  we  not  include  as  a  routine  the 
observation  as  to  carious  teeth  and  a  recognition 
of  these  four  periods  of  eruption  coincident  with 
slight  enlargement?" 

C.  F.  Cobb:  "For  years  no  one  has  imder- 
stood  the  importance  of  the  tonsil,  and,  being 
considered  useless,  it  has  been  removed  freely. 

"The  tonsil  lies  between  the  pillars  attached  to 
the  fascia  of  the  superior  pharyngeal  muscle  pro- 
tected in  front  and  rear  by  the  pillars  to  one-half 
or  more  of  its  extent.  From  the  pillars  anterior 
and  posterior  a  reflexion  of  mucous  membrane 
comes  to  the  tonsil,  making  it,  when  at  rest,  re- 
semble a  telescope  one-half  closed.  Were  it  not 
for  this  reflexion  of  mucous  membrane,  the  con- 
traction and  expansion  of  the  organ  would  be 
checked  by  the  mucous  membrane  about  it  and 
great  pain  would  result  on  any  enlargement  of 
the  gland.  This  arrangement  seems  to  show  that 
nature  intended  the  tonsil  to  be  free  to  change  its 
shape  in  accordance  with  alterations  in  size  due 
to  some  functional  activity.  And  this  agrees 
with  clinical  facts,  for  we  find  tonsils  now  large, 
now  small,  at  one  time  recommended  for  opera- 
tion, and  a  few  weeks  later,  when  the  date  ar- 
rives, of  such  reasonable  proportions  that  no 
operation  seemed  wise. 

"Of  late  years,  theories  of  absorption  from  ton- 
sils have  come  in  and  tonsils  have  been  con- 
demned on  slight  evidence  and  removed. 

"Let  us  take  two  hypotheses:  First,  that  the 
tonsil  is  an  organ  for  infection  or  absorption; 
second,  that  it  is  a  protective  organ.    First  then, 


112  THE    TONSILS    AND    THE    VOICE 

acute  tonsillitis  affects  the  tonsil  and  gives  rise  to 
toxic  symptoms.  Tuberculosis  enters  by  the 
tonsil  at  times  and  tubercle  bacilli  have  been 
found  in  the  follicles  of  the  tonsil.  Rheumatism 
is  said  to  be  a  result  of  tonsillar  absorption. 

"Of  course,  it  is  claimed  by  many  advocates  of 
this  theory  that  the  tonsils  causing  such  troubles 
are  diseased  tonsils,  but  practically,  as  disease 
can  only  be  determined  in  most  cases  by  removal 
of  the  tonsils  and  examination  under  the  micro- 
scope, the  result  has  been  the  removal  of  healthy 
tonsils,  the  working  theory  being  that  the  tonsil 
might  form  the  source  of  infection;  and  in  any 
case  no  harm  could  be  done. 

"Now  let  us  discuss  the  probabilities,  as  seen 
from  an  anatomical  and  pathological  standpoint, 
of  the  question  whether  the  tonsil  is  an  absorp- 
tive or  protective  organ. 

"If  the  tonsil  were  intended  to  absorb  poison- 
ous substances,  why  should  nature  give  them  to 
young  and  tender  children  and  allow  them  to 
atrophy  as  the  person  grows  older? 

"Why  should  nature  surround  the  tonsil  with 
chains  of  lymphatic  glands  which  resist  infection 
into  the  general  System? 

"How  is  it  that  millions  of  staphylococci,  the 
poison  of  which  to  a  mild  extent  reaches  the  gen- 
eral system,  causing  a  fever  for  a  day  or  two,  can 
be  cared  for  by  this  maligned  organ,  when  a  very, 
very  few,  in  a  wound,  may  result  fatally  ? 

"But  it  will  be  said.  Does  not  tuberculosis 
sometimes  get  in  in  this  way  ? 

"It  is  true,  probably,  that  it  does,  but  it  is  also 
true  that  because  a  sentinel  is  sometimes  over- 


THE    TONSILS    AND    THE    TEETH  II3 

powered  by  an  enemy  a  wise  commander  does  not 
abolish  all  sentinels.  There  are  other  channels 
for  tuberculosis.  We  find  them  in  Peyer's 
patches  in  the  intestine  and  in  the  glands  which 
drain  the  bronchi  of  the  lung.  Who  suggests 
the  wisdom  of  destroying  such  organs  because 
they  have  failed  in  their  efforts  to  protect  us  ? 

"Now,  Dr.  Wright  tells  us  that  the  tonsil 
serves  as  a  sentinel  for  the  protection  of  the  sys- 
tem from  the  products  of  dental  infection,  and 
this  idea  is  borne  out  by  common  sense,  by  clinical 
experience  and  by  theory. 

"I  have  myself  watched  the  improvement  in 
size  of  tonsils  after  the  removal  of  bad,  rotting 
teeth.  This  function  is,  perhaps,  one  and  not  the 
only  function,  but  it  is  enough  to  justify  the  ton- 
sil's presence ;  and  our  gratitude  is  due  to  him  for 
clearing  up  this  point.  Do  not  misunderstand 
these  remarks.  Removal  of  obstructing  tonsils 
when  breathing,  swallowing,  or  disease  is  present, 
is  justifiable  and  wise,  but  radical  extirpation 
should  only  be  done  where  disease  of  the  tonsils, 
chronic  tonsillitis  or  peritonsilar  abscess  make  it 
necessary,  and  this  rule  is  especially  true  in  early 
youth."  {Boston  Medical  and  Surgical  Jour- 
nal  May  20,  1909.) 

A.  Coolidge,  Jr.:  "A  considerable  variation 
in  the  size  of  the  pharyngeal  or  faucial  tonsil 
must  be  looked  upon  as  within  normal  limits. 
The  lymphoid  tissue  may  become  increased  in 
amount  to  an  extent  to  be  considered  pathologi- 
cal, either  as  a  whole  or  in  one  or  more  of  the 
tonsillar  masses.  This  increase  over  the  normal 
amount  takes  place  almost  exclusively  in  chil- 

9 


114  THE    TONSILS    AND    THE    VOICE 

dren,  although  once  estabUshed,  it  may  persist 
into  later  life.  It  is  of  especial  importance  in 
the  naso-pharyngeal  space,  where  it  is  commonly 
called  'adenoids'  and  in  the  faucial  tonsils,  when 
the  patient  is  said  to  have  enlarged  or  hypertro- 
phied  tonsils. 

"Among  the  causes  to  which  we  must  look  for 
tonsillar  enlargement,  Dr.  Wright  now  adds  cer- 
tain conditions  of  the  teeth."  {Boston  Medical 
and  Surgical  Journal^  May  20,  1909.) 

G.  Hxidson-Makuen:  "The  Faucial  Tonsils 
and  the  Teeth,"  June,  1909:  "Diseased  faucial 
tonsils  affect  the  teeth  in  three  ways.  First,  they 
interfere  with  the  general  health  of  the  patient 
and  thus  with  the  proper  nourishment  of  the 
teeth.  Second,  they  contribute  very  largely  to 
the  local  invasion  of  the  teeth  by  the  numerous 
bacteria  which  emanate  from  their  crypts.  And 
third,  they  interfere  by  pressure  with  the  align- 
ment of  the  teeth  and  with  the  normal  develop- 
ment of  the  maxillarj^  bones. 

"AVe  cannot  cure  mouth-breathing  and  its  re- 
sultant disastrous  effects,  in  all  cases,  merely  by 
the  removal  of  tonsils  and  adenoids.  When 
there  are  dental  irregularities  which  make  it  im- 
possible, difficult  or  even  a  little  inconvenient  to 
close  the  mouth,  something  more  than  tonsillec- 
tomj^  and  adenoidectomy  must  be  done." 

After  removal  of  the  wisdom  teeth  the  back 
part  of  the  roof  of  the  mouth  will  sometimes  sink 
or  drop  down  to  the  extent  of  fully  a  quarter  of 
an  inch.  The  removal  of  tonsils,  also,  according 
to  Von  Chiari,  will  cause  the  roof  to  fall  down  in 


THE    TONSILS    AND    THE    TEETH  II5 

a  similar  manner — the  tonsils  act  as  a  prop  or 
support  to  the  back  part  of  the  roof  of  the  mouth. 

A  high,  narrow  palatal  arch  is  often  associated 
with  a  deflected  septum  and  irregular  teeth. 
Sturmann  {Berliner  Klinische  W ochenschrift , 
June,  1912)  employed  a  brace  for  two  and  a  half 
months  and  made  the  palate  and  septum  practi- 
cally normal. 

William  S.  Flower,  an  able,  experienced  and 
conscientious  dentist,  has  suggested  that  "in  new- 
born babes  it  is  a  good  practice  to  make  a  habit 
of  pressing  the  thumb  firmly  against  the  roof  of 
the  mouth;  that  this  practice  spreads  the  upper 
jaw,  and  widens  the  roof,  preventing  a  saddle- 
back formation  of  the  jaw;  and  later  facilitates 
the  ease  in  eruption  of  the  molar  teeth  and  helps 
to  prevent  the  development  of  irregularities;  by 
widening  the  jaw  it  causes  the  roof  to  fall  to  an 
extent,  creating  thereby  a  more  roomy,  better 
drained  and  better  ventilated  post  nares." 
Flower  states  that  "the  tonsils  are  more  often  af- 
fected from  disease  of  the  gums  about  the  necks 
than  the  roots  of  the  teeth." 

The  habit  of  the  Indians  in  tying  up  the 
mouth  of  their  new-born  babes,  so  as  to  force 
them  to  breathe  through  the  nose,  is  an  excellent 
practice,  and  may  help  to  account  for  the  fine 
nasal  respiration  and  the  absence  of  "adenoids" 
in  this  race. 

Recently,  a  young  lady  applied  to  me,  with 
the  statement  that:  "I  have  a  severe  pain  in  the 
left  side  of  my  face,  so  severe  that  I  have  had  no 
sleep  for  fourteen  days  and  nights.  My  physi- 
cian says  that  I  have  disease  in  the  antrum  and 


116  THE    TONSILS    AND    THE    VOICE 

that  I  must  be  operated  upon,  and  has  directed 
me  to  see  a  speciaUst  on  the  nose." 

I  examined  her  carefully,  found  no  disease  in 
the  antrum,  but  that  her  teeth  were  causing  the 
pain.  She  said,  "I  have  seen  my  dentist  and  he 
has  assured  me  that  my  teeth  are  all  right  and 
that  they  have  nothing  to  do  with  the  pain,  but 
that  the  antrum  is  diseased." 

I  answered  that  if  she  had  no  objection,  we 
would  consult  my  dentist.  We  did  so,  and  he 
discovered  that  the  pain  in  her  face  was  caused 
b}^  a  tooth  that  was  pressing  hard  againfft  its 
neighbor.  Pressure  was  at  once  removed  and  the 
pain  of  fourteen  days  ceased  instantly. 

A  gentleman  applied  to  me,  saying:  "I  have 
been  to  a  specialist  who  has  told  me  that  the  bones 
in  my  right  cheek  are  dead,  and  that  I  must  go  to 
the  hospital  and  have  them  removed  to  relieve  the 
severe  pain  in  my  right  cheek."  After  careful 
examination,  I  said  to  him:  "The  bones  in  your 
right  antrum  are  not  at  all  diseased,  but  your 
trouble  comes  from  your  eye  tooth."  We  con- 
sulted Flower,  who  confirmed  my  diagnosis, 
and  by  attending  to  the  tooth,  the  trouble  in  the 
face  quickly  disappeared. 

In  another  case  a  young  lady  suffered  from 
severe  pain  in  her  ear.  She  was  told  by  a  special- 
ist that  she  had  mastoid  disease,  and  that  the  mas- 
toid operation  was  imperative  at  once  to  relieve 
the  pain.  The  mastoid  operation  was  per- 
formed, but  the  pain  did  not  abate.  In  several 
days  after  the  operation,  she  cut  a  wisdom  tooth 
and  the  pain  disappeared  immediately. 


CHAPTER  VIII 
SIX  MEDICAL  QUESTIONS. 

Question  Number  One. 

Have  the  normal  faucial  tonsils  any  function: 
physiologic,  biologic,  chemical,  phonetic  or  other  ? 

By  normal  faucial  tonsils,  I  mean  the  ton- 
sils situated  in  the  fauces,  between  the  anterior 
and  posterior  palatine  arches,  in  healthy  condi- 
tion, and  of  such  size  as  not  to  project  beyond 
the  line  of  the  palatine  arches,  nor  press  upon 
surrounding  tissues,  of  a  size  so  small  as  not  to 
interfere  with  the  perfect  anatomical  outlines  of 
the  walls  of  the  pharynx. 

Answers : 

H.  Holhrooh  Curtis:  "In  my  opinion — no." 

Eugene  H.  Hodenpyl:  "The  function  of  the 
tonsil  is  unknown." 

G.  Hudson-Makuen:  "The  question  in  my 
mind  is  still  sub  judice." 

A.  Coolidge,  Jr.:  "I  do  not  believe  that  any 
one  knows.  The  fact  that  they  are  there  should 
be  presumptive  evidence  that  they  have." 

Edwin  Pynchon:  "If  the  tonsils  have  any 
function  at  all,  it  must  be  only  in  babyhood  or  the 
early  years  of  life,  as  Nature's  apparent  effort  is 
to  diminish  them  in  size — so-called  atrophy.  I 
claim  this  atrophy  is  more  apparent  than  real, 
being  largely  a  transition  from  protrusion  to  sub- 
mersion.    In  the  change  the  lymphoid  element  is 

117 


118  THE    TONSILS    AND    THE    VOICE 

absorbed  or  destroyed  and  the  glandular  element 
relatively  increased.  The  disadvantageous  fea- 
ture of  it  is  that  this  change  is  produced  by  and 
through  a  low  grade  of  inflammatory  action,  re- 
sulting in  an  increase  of  tonsillar  secretion  of  bad 
character  which  increases  troubles  in  both  the 
pulmonary  and  gastro-intestinal  tracts.  While 
when  submerged  it  may  be  claimed  that  thej^-  do 
not  interfere  with  the  outline  of  the  walls  of  the 
pharynx,  they  at  any  rate  fill  a  space  which 
should  be  concave  like  an  inverted  trough.  In- 
wardly they  ma}^  also  exert  pressure  as  on  the 
Eustachian  tube,  etc." 

A.  Barth:  "About  the  importance  and  func- 
tion of  the  faucial  tonsils  I  have  my  ideas  formed 
from  the  literature  and  our  own  observations. 
But  I  think  that  in  a  collective  research,  to  have 
scientific  value,  only  personal  researches  should 
be  considered.  These  are  not  considered  in  this 
question." 

George  B.  Wood:  "I  cannot  accept  your  defi- 
nition of  what  is  a  normal  faucial  tonsil,  as  I  be- 
lieve that  large  tonsils  may  be  a  personal  idiosyn- 
cracy  and  not  the  result  of  disease,  just  as  in  the 
nose — sometimes  big  and  sometimes  small.  As 
to  their  function  they  undoubtedly  form  lym- 
phocytes in  the  germinating  follicles,  and,  ac- 
cording to  my  belief,  also  form  a  metamorphosis 
of  the  epithelial  cells  of  the  crypts.  Further 
than  this  they  have  not  been  proven  to  havie  any 
function."  .   ,  j  , 

J.  Maclntyre:  "With  regard  to  the  first  two 
questions,  I  really  cannot  pretend  to  say  more 
than  is  recorded  in  our  text-books." 


SIX    MEDICAL   QUESTIONS  119 

J,  E.  Newcomh:  "Have  made  no  special 
studies  in  this  direction," 

E.  M.  Holmes:  "I  have  made  no  original  re- 
search, and  therefore  my  opinion  is  without 
weight." 

E.  W.  Scripture:  "No  phonetic  use  known. 
Enlarged  tonsils  change  the  timbre  of  the  voice." 

C.  H.  Knight:  "I  presume  they  have." 

Sir  Felice  Seiiion:  "In  reply  to  your  inquiry,  I 
beg  to  say  that  I  do  not  know  enough  of  the 
physiological  role  of  the  f  aucial  tonsils  to  give  an 
apodictic  opinion  in  a  few  lines.  In  my  lectures, 
'Some  Thoughts  on  the  Principles  of  Treatment 
in  Diseases  of  the  Upper- Air  Passages'  (British 
Medical  Journal,  November  2  and  9,  1901),  I 
have  energetically  protested  against  operative  in- 
temperance in  my  specialty  and  need  not  say 
that  I  should  consider  removal  of  normal 
tonsils  an  absolutely  inadmissible  proceeding, 
which  could  not  be  condemned  severely  enough. 
In  Volume  XIII  of  the  Reports  of  St.  Thomas's 
Hospital  (London) J,  you  will  find  under  the 
heading,  '^The  Throat  Department  of  St. 
Thomas's  Hospital  in  1883/  quite  a  lengthy  arti- 
cle from  me  on  'The  Indications  for,  and  Meth- 
ods of.  Removal  of  the  Tonsils/  which  will  give 
you  full  particulars  on  several  of  the  questions 
concerning  which  you  wish  my  opinion.  What 
seems  to  me  most  important  is :  to  keep  the  happy 
medium  between  operative  intemperance  and  the 
happy-go-lucky  operative  inactivity." 

Lubet-Barbon:  "I  do  not  know  the  function 
of  normal  tonsils." 


120  THE    TONSILS    AND    THE    VOICE 

Luc:  "No  personal  experience  nor  views  on 
the  subject." 

Beverly  Robinson:  "I  believe  so." 

John  N.  Mackenzie:  "I  can  add  nothing  defi- 
nite to  our  imperfect  knowledge  of  the  subject. 
I  believe  that  the  tonsils  were  put  into  the  throat 
of  man  with  good,  and  not  evil,  intents  to  serve 
a  physiological  rather  than  a  pathological  pur- 
pose and  that  if  they  were  originally  intended  as 
easy  and  natural  avenues  of  infection,  then  na- 
ture made  a  poorer  job  of  it  than  she  did  in  the 
case  of  other  portals  of  germ  entrance,  such,  for 
example,  as  the  respiratory  passages." 

St.  Clair  Thomson:  "I  think  they  must  serve 
some  function  in  quite  early  life." 

Wesley  Mills:  "I  believe  they  have,  though  I 
do  not  feel  justified  in  teaching  that  to  my  stu- 
dents. I  think  their  function  is  so  slight  that 
they  can  in  their  work  be  readily  compensated  for 
by  other  organs.  I  am  inclined  to  think  that 
they  are  related  to  the  glandular  system  in  some 
Avay." 

E.  B.  Gleason:  "I  believe  they  have  other  func- 
tions beside  those  in  common  with  other  portions 
of  the  lymphatic  system." 

George  L.  Ross:  "Undoubtedly.  Especially 
physiological  and  chemical,  but  I  have  never  fol- 
lowed this  question  in  the  physiological  labora- 
try  and  therefore  am  not  prepared  to  furnish 
facts." 

George  B.  Rice:  "Yes." 

J.  W.  Gleitsniann:  "The  normal  faucial  tonsil 
has  in  my  opinion  a  physiological  function." 


SIX   MEDICAL   QUESTIONS  X2I 

William  E.  Casselberry:  "Yes;  to  the  best  of 
my  knowledge  and  belief." 

Frank  E.  Miller:  "Lubricates  principally. 
Remove  tonsil  with  capsules  and  atrophic 
pharyngitis  ensues,  also  adhesion  of  pillars. 
Regulators  of  pillar  action  and  secretions.  They 
are  indices  of  intestinal  changes,  hence  assist 
chemistry  of  the  stomach  and  intestines  princi- 
pally on  account  of  response  to  alkaline  applica- 
tions. As  lubrication  and  regulation  of  phonetic 
muscles  are  involved  in  the  working  of  a  normal 
tonsil  to  such  an  extent  is  voice  impaired.  A 
healthy  tonsil  in  some  throats  is  never  seen,  ex- 
cept by  means  of  pulling  out  of  the  way  the  ante- 
rior palatine  wall,  otherwise  the  arrangement  of 
the  parts  are  abnormal." 

Von  Chiari:  "Most  probably  the  tonsils  serve 
for  the  purpose  of  formation  of  leucocytes." 

Massei:  "I  believe  the  tonsils  (the  faucial  nor- 
mal )  have  a  biologic  function  similar  to  the  lym- 
phatic tissue  which  forms  the  so-called  Waldeyer 
ring." 

Escat:  "I  am  of  the  opinion  that  the  faucial 
tonsils  have  not  for  their  only  function  that  of 
phagocytosis  studied  by  Metchnikojf,  but  also  a 
physiological  and  biological  function,  due  to  an 
internal  secretion,  like  all  the  secretory  internal 
glands  (thymus,  thyroid,  liver,  etc.)." 

Moure:  "I  consider  that  the  normal  tonsils 
have  physiologic,  biologic,  chemical  and  phonetic 
functions.  There  is  no  doubt  that  they  are  the 
advanced  sentinels  of  the  rear  throat,  defending 
the  entrance  of  the  air  passages,  upper  and  lower. 
They  do  not  appear  to  play  an  important  phago- 


122  THE   TONSILS   AND   THE   VOICE 

cytic  role,  from  a  biological  point  of  view.  From 
a  phonetic  point  of  view  their  normal  role  must 
evidently  be  to  prevent  in  a  certain  measure  the 
nasality  (nasonnement)  by  maintaining  the  pil- 
lars in  the  midst  of  which  they  are  placed." 

Schmiegelow:  "I  look  upon  the  tonsils  as  a 
part  of  the  protecting  system  which  is  repre- 
sented by  all  the  lymphoid  tissue  to  be  found 
everywhere  in  the  mucous  membrane  of  the 
pharynx  and  nasopharynx." 

Van  Bag  gen:  "The  faucial  tonsils  have  cer- 
tainly a  phonetic  function.  Their  situation  in 
the  mouth  at  a  place  where  the  voice  receives  an 
essential  part  of  its  specific  qualities  allows  us  to 
admit  this  assertion.  The  muscles  of  the  anterior 
and  posterior  pillars  of  the  fauces  between  which 
the  tonsils  rest,  are  in  constant  movement,  when 
we  are  speaking  or  singing.  Their  action  com- 
bined with  the  movements  of  the  muscles  of  the 
soft  palate  changes  the  shape  of  the  voice  passage 
at  the  back  of  the  mouth  when  we  are  forming 
the  different  vocals  or  producing  tones  of  differ- 
ent pitch.  The  position  of  the  tonsils,  situated  as 
they  are  between  the  pillars  of  the  fauces,  are  of 
great  importance  with  regard  to  the  exactitude 
and  perfectness  of  those  movements.  Also  for 
the  resonance  the  tonsils  are  of  great  interest  for 
the  voice.  With  their  spongy  tissue,  they  can  be 
compared  to  the  felt  in  the  piano  which  softens 
the  tone  and  regulates  the  resonance." 


SIX    MEDICAL    QUESTIONS  123 

ADDENDA  TO  QUESTION  NUMBER 
ONE  FROM  ORIGINAL  SOURCES. 

Elaborate  researches  have  been  made  into  the 
anatomy  and  physiology  of  the  faucial  tonsils, 
and  many  minute  anatomical  data  have  been  posi- 
tively ascertained  and  repeatedly  verified  and 
authenticated  by  trained  and  able  investigators. 

Retterer,  Journal  de  V Anatomic,  1888,  "The 
Origin  and  Evolution  of  the  Tonsils" :  "Proved 
the  existence  of  clear  germinating  centers  in  the 
follicle  of  the  tonsils.  Proved  the  existence  of 
lymphatic  vessels  occupying  the  whole  follicular 
mass  of  the  tonsils,  and  forming  a  system  of 
closed  lymphatic  canals  which  do  not  open  into 
the  connective  tissue  reticulum  by  stomata  or  by 
their  extremities.  He  proved  that  the  periphery 
of  the  lobules  is  more  vascular  than  the  center." 

Marcel  Labbe  and  Ch.  Levi-Sirugue:  ''Re- 
searches on  the  Structure  and  Physiology  of  the 
Tonsils"  Work  done  in  the  laboratory  of  Pro- 
fessor Landouzy,  at  the  Laennec  Hospital,  Re- 
port published  in  the  Bulletin  of  the  Anatomical 
Society  of  Paris,  July,  1899. 

"What  we  have  chiefly  sought  to  do  is  to  defi- 
nitel}^  determine  the  nature  and  distribution  of 
the  cellular  forms  which  are  met  with  in  the  inte- 
rior of  the  tonsil,  the  constitution  of  the  follicles 
and  their  relation  to  the  lymphatic  passages,  and 
thus  deduct  as  far  as  possible,  their  physiology. 
The  tonsil  was  considered  in  times  past  as  an 
organ  designed  to  secrete  mucus  to  lubricate  the 
alim.entarv  bolus,  but  this  function  does  not  be- 


124  THE    TONSILS    AND    THE    VOICE 

long  to  the  tonsil,  but  really  to  the  glands  in 
groups  which  are  outside  of  it." 

"The  phenomena  of  absorption^  at  the  level  of 
the  tonsils  has  been  studied  experimentally.  The 
epithelium  prevents  absorj)tion  which  only  be- 
comes possible  if  it  is  destroyed,  or  if  the  sub- 
stances are  introduced  under  the  epithelial  bed, 
and  even  under  these  conditions  the  absorption  is 
very  slow." 

The  most  exhaustive  and  valuable  laboratory 
research  investigations  on  the  tonsils  have  been 
made  by  Retterer,  Labhe  and  Sirugue.  Labora- 
tory investigations  of  Stohr,  Von  Lendrt^  Poli 
and  Frederici,  Krause,  Briegei^  Goerke,  Westen- 
hoefer,  Merkel,  Most,  Groher,  Hodenpyl,  Flem- 
ming  and  Von  Levinstein  are  important.  So  are 
the  clinical  observations  of  Jacohi  and  Frdnkel. 
The  works  of  Gulland,  Fox,  Spicer,  Menzer, 
Lexer,  Heridelssohn,  Kilmmel,  Lindt,  Kayser, 
Allen,  Masini,  Pugnat,  Pluder,  Schoenemann, 
Broeckhaert,  Wright,  Asliurst,  Lichtwitz  and 
Sahrages  and  Hicguet  are  valuable.  The  works 
of  Goodale,  Bosworth,  Wood  and  a  few  others 
are  interesting.  And  beyond  these  are  more 
than  one  thousand  monographs  that  burden  the 
subject. 

Labbe  and  Sirugue:  "From  the  absolute  anal- 
ogy of  the  internal  structure  of  the  tonsil,  with 
that  of  the  ganglions  (lymphatic) ,  the  spleen  and 
the  closed  follicles  of  the  intestines,  we  have  a 
right  to  conclude,  contrary  to  the  opinion  of  Bet- 
terer,  that  the  tonsils  are  assimilable  to  the  gan- 
glions. Like  them,  they  have  a  role  in  the  hema- 
topsis.     The  germinative   centers   of  the  tonsil 


SIX   MEDICAL   QUESTIONS  125 

have  certainly  the  same  functions  as  those  of  the 
gangHons  which  are,  as  Flemming  has  shown,  the 
locaHties  for  the  production  of  leucocytes." 

"There  is  also  in  the  germinative  centers  of 
the  tonsil,  as  in  those  organs  of  which  the  struc- 
ture is  analogous,  an  incessant  cellular  renova- 
tion. Stohr  admits  the  passage  of  leucocytes 
through  the  epithelium  of  the  tonsil  into  the  buc- 
cal cavity.  The  epithelium  has  the  same  protec- 
tive role  at  the  level  of  the  tonsils  as  at  the  level 
of  the  rest  of  the  buccal  mucosa.  The  crypts 
augment  its  extent.  Even  in  the  normal  state 
the  epithelium  is  always  more  or  less  irritated, 
and  above  all  at  the  bottom  of  the  crypts,  and  we 
have  seen  that  it  is  the  seat  of  the  incessant  phe- 
nomena of  cellular  renovation.  This  epithelial 
irritation  is  due  to  the  presence  of  dust,  of  small 
foreign  bodies,  which  penetrate  into  the  crypts; 
it  is  due,  above  all,  to  the  existence  at  the  surface 
of  the  tonsil  of  pathogenic  microbes,  which  are 
found  constantly  in  the  normal  state.  Netter, 
Bezanson  and  Griff  en  have  observed  the  constant 
presence  of  pneumococci  at  the  surface  of  the 
tonsil,  generally  associated  with  streptococci. 
Cornil  had  already  seen  that  tubercle  bacilli  meet 
at  the  surface  of  the  crypts  in  normal  individuals, 
in  the  same  way  as  Strauss  has  observed  on  the 
surface  of  the  nasal  mucosa.  These  microbes, 
although  in  the  crypts,  are  on  the  eooterior  of  the 
tonsil,  and  it  is  the  defense  reaction  of  the  epithe- 
lium which  prevents  their  penetration.  It  is  only 
when  the  epithelium  has  been  destroyed  that  the 
microbes  penetrate,  and  in  such  case  they  rarely 
pass  beyond  the  conjunctive  bed;  it  is  only  in  the 


126  THE    TONSILS    AND    THE    VOICE 

case  of  the  complete  destruction  of  the  tonsil  that 
they  may  be  found  in  the  follicles/' 

Hodenpyl  "confirmed  the  observation  of  Ret- 
terer  that  the  Ij^mph  net  occupies  the  whole  fol- 
hcular  mass  of  the  tonsils  and  forms  a  system  of 
closed  canals  which  do  not  open  into  the  reticu- 
lum. Hodenpyl  tried,  but  could  not  procure  any 
absorption  by  the  tonsil  from  its  surface." 

Groher:  "The  Tonsils  as  a  Port  of  Entry  for 
tubercle-bacilli" :  "The  microbes  having  entered 
the  tonsil,  are  mostly  destroyed  because  the  serum 
kills  them ;  the  power  of  the  leucocytes  as  phago- 
cytes kills  them  also.  It  is  also  possible  that  the 
microbes  enter  the  sj^stem  through  the  blood-ves- 
sels. The  tonsils  seem  to  be  a  less  favorite  set- 
tling place  for  tubercle-bacilli  than  the  lymph 
glands,  for  we  find  scrofulous  glands  oftener  than 
infections  of  the  tonsils.  JNIany  authors  have 
considered  diseased  tonsils  as  more  liable  to  mi- 
crobial infection  than  healthy  ones.  If  that  is 
true  it  has  not  been  proven." 

Metchnikoff:  "Some  years  ago  Stohr  demon- 
strated that  the  walls  of  the  tonsils,  and  especially 
the  tonsils  and  other  lymphoid  organs,  are  tra- 
versed b}^  an  enormous  number  of  leucocj^tes, 
which  execute  a  kind  of  immigration  towards  the 
cavities  containing  micro-organisms.  This  con- 
tinual and  normal  condition  is  often  termed 
Stohr' s  phenomenon,  and  when  we  remove  a  par- 
ticle of  mucus  from  the  surface  of  the  tonsils  of 
a  person  in  good  health  we  always  find  that  it 
contains  leucocytes,  especially  microphages,  filled 
with  micro-organisms  of  all  kinds." 

Von  Levinstein:  "As  we  find  in  normal  tonsils 


SIX   MEDICAL   QUESTIONS  127 

always  follicles  with  cell-producing  centers,  we 
can  claim  with  surety  that  in  the  normal  tonsil 
young  lymphocytes  are  produced,  and  that  in  the 
hyperplastic  tonsils  the  number  of  newly  formed 
lymphocytes  is  always  considerably  larger  than 
in  the  normal  tonsil.  In  the  atrophic  tonsil 
young  lymphocytes  are  not  found.  What  be- 
comes of  these  young  lymphocytes  is  not  decided. 
That  they  are  put  into  the  circulation  has  to  be 
considered  doubtful,  so  long  as  it  is  not  proved 
that  the  vasa  efferentia  of  the  tonsils  contain  a 
larger  amount  of  lymphocytes  than  the  vasa  af- 
ferentia.  So  far  this  has  not  been  proved  and  it 
will  be  difficult  to  prove  because  it  is  impossible 
to  say  which  are  the  afferentia  and  which  the  ef- 
ferentia. We  have  also  to  mention  the  fact  that 
not  a  small  number  leave  the  tonsil  by  wandering 
through  the  epithelium  to  the  surface  of  the 
organ,  or  into  the  lumen  of  the  fossula.  I  have 
proved  in  my  work  that  a  considerably  larger 
number  of  lymphocytes  leave  the  hyperplastic 
organ  than  the  normal  tonsils.  We  know  the 
fact  that  young  lymphocytes  are  in  the  tonsils." 

Frdnkel:  "The  Infectious  Diseases  of  the 
Pharynx." 

"The  ideas  about  the  function  of  the  tonsils 
have  materially  changed  within  the  last  thirty 
years,  through  the  discovery  of  Stohr,  that  an 
interrupted  immigration  of,  Stohr  believes,  leuco- 
cytes takes  place  from  the  follicles  and  the 
adenoid  substances  of  the  tissue  surrounding  the 
fossula.  One  sees  the  leucocytes  passing  through 
the   epithelium.      This   immigration    at   certain 


128  THE    TONSILS    AND    THE    VOICE 

places  is  so  strong  that  it  is  difficult  to  find  the 
epithelium." 

Jacohi  (Archives  of  Pediatrics,  July,  1906) : 
"Cases  of  membranous  throat  diseases  behave  dif- 
ferently according  to  their  location.  Now,  when- 
ever the  membrane  is  limited  to  the  tonsil  there 
is  very  little,  or  no,  glandular  swelling  in  the 
neighborhood.  On  the  other  hand,  if  a  mem- 
brane extends  from  a  tonsil  to  its  neighborhood, 
or  starts  at  a  distance  from  the  tonsil,  neigh- 
boring lymph  bodies  swell  at  once.  Again,  the 
treatment  of  this  neighborhood  shows  itself 
almost  immediately  on  the  swelled  glands.  That 
is  mostly  evident  when  the  seat  of  the  membrane 
is  anywhere  in  the  posterior  nares  which  excel  by 
an  immense  network  of  lymphatics.  On  the 
other  hand,  when  it  covers  the  vocal  cords,  and 
Morgagni's  fossa,  both  of  which  have  a  scanty 
network  of  lymphatics,  there  \&  no  adenitis,  nor 
any  constitutional  symptoms.  These  clinical  ob- 
servations have  stood  the  test  of  time  and  must 
be  reckoned  with." 

"One  of  the  tonsil's  functions  is  surely  that  of 
either  preparing  or  storing  leucocytes. 

"It  has  not  been  possible,  thus  far,  to  verify 
the  existence  of  afferent  or  efferent  ducts  of  their 
own.  The  practical  deduction  from  this  is,  that 
the  tonsils  have  little  or  no  connection  with  the 
lymphatic  system.  The  number  of  blood  vessels 
in  the  normal  tonsils  is  not  large,  and  it  becomes 
greatly  diminished  when  that  organ  has  become 
the  seat  of  repeated  chronic  inflammation." 

Jacohi  {Medical  Record,  August  19,  1911)  : 
"Does  not  believe  the  removal  of  tonsils  should 


SIX   MEDICAL   QUESTIONS  129 

be  done  as  often  as  some  gentlemen  seem  to  think. 
It  was  probable  that  the  infection  of  rheumatism 
and  scarlet  fever  through  the  capsule  was  not 
so  frequent ;  it  more  likely  took  place  through  the 
soft  lymphodes  of  the  Waldeyer  ring."  He  em- 
phasized the  desirability  of  keeping  the  nares 
clear,  both  before  and  after  operation.  "If  there 
were  greater  care  exercised  in  this  respect,  so 
many  operations  on  the  tonsils  would  probably 
not  be  necessary." 

Sir  Felice  Semon  (St.  Thomas's  Hospital  Re- 
port): "I  recommend  that  the  tonsils  be  reduced 
in  size: 

(1)  If  they  interfere  with  respiration  and 
lead  to  insufficient  oxygenation  of  the  blood. 

(2)  If  they  lead  to  change  in  the  character  of 
the  voice  and  to  defective  articulation. 

(3)  If  they  lead  to  defective  development  of 
the  face  and  chest. 

(4)  If  the  chronic  enlargement  be  attended 
by  frequent  attacks  of  inflammation  of  the  ton- 
sils themselves,  by  tumefaction  of  the  cervical 
lymphatic  glands,  or  by  catarrhal  conditions  of 
the  neighboring  mucous  membranes,  notably  of 
the  Eustachian  tubes.  The  common  characteris- 
tics of  these  indications  are,  it  will  be  observed, 
that  all  of  them  are  conditional,  not  absolute.  In 
other  words,  I  recommend  a  surgical  interfer- 
ence with  enlarged  tonsils  only  when  they  cause 
any  of  the  serious  symptoms  above  enumerated, 
and  not  merely  on  account  of  the  enlargement 
per  se." 

"The  term,  'large  tonsils'  is  one  that  can  only 
xo 


130  THE    TONSILS    AND    THE    VOICE 

be  used  relatively.  Comparatively  large  tonsils 
in  a  roomy  pharynx  are  no  doubt  much  less  mis- 
chievous per  se,  than  much  smaller  ones  in  a  nat- 
urally very  narrow  throat. 

''Supposing  that  the  former  do  not  interfere 
with  any  of  the  functions  of  the  part  nor  lead  to 
inflammation,  etc.,  there  is  in  my  opinion  not  the 
slightest  reason  to  interfere  with  them." 

"It  is  by  no  means  rare  for  children  to  be 
brought  to  me  simply  because  it  has  been  acci- 
dentally discovered  that  their  tonsils  are  large. 
If  in  such  cases  I  cannot  satisfy  myself  that  any 
of  the  graver  consequences  are  present,  I  never 
interfere.  It  is  only  when  I  find  that  any  or 
several  of  the  symptoms  mentioned  in  my  list  are 
present  that  I  strongly  insist  on  the  undesira- 
bility  of  either  leaving  matters  alone  or  losing 
precious  time  by  having  recourse  to  inefficient 
measures.  I  wish  to  emphasize  the  distinction 
thus  made,  lest  it  should  he  inferred  from  the 
tone  of  my  foregoing  remarks,  that  I  am  a  fanat- 
ical advocate  of  surgical  interference  as  soon  as 
an  enlargement  of  the  glands  is  discovered. 
Nothing,  indeed,  could  be  more  alien  to  my  inten- 
tions.'' 

"I  have  no  doubt  that  tonsils  can  be  equally 
well  removed  by  very  different  methods.  I  con- 
sider total  enucleation  not  only  dangerous,  but 
also  generally  superfluous.  The  tonsil  project- 
ing under  normal  conditions  nearly  or  quite  up 
to,  or  even  a  little  beyond,  the  palatine  arches, 
it  ought  to  be  the  aim  of  the  operator  to  reduce 
them,  in  cases  of  hyperplasia,  to  their  normal 
size." 


SIX    MEDICAL    QUESTIONS  131 

Adami  and  Nicholls  (Principles  of  Pathology, 
Vol.  2,  1909)  say:  "The  tonsils  appear  to  have 
an  important  function.  While  the  lymphoid  cells 
are  themselves,  to  a  limited  degree,  phagocytic, 
polymorphonuclear  leucocytes  in  considerable 
numbers  make  their  way  from  the  blood  vessels 
to  the  surface  through  the  epithelial  covering. 
These  leucocytes  are  strongly  phagocytic  and 
their  activity  suggests  that  the  tonsils  form  one 
of  the  barriers  against  the  invasion  of  the  system 
by  pathogenic  micro-organisms." 


132  THE    TONSILS    AND    THE    VOICE 

ADDENDA  INTRODUCED  ESPE- 
CIALLY FOR  THE  PURPOSE  OF 
SHOWING  THE  WIDE  DIVERSITY  OF 
MEDICAL  VIEWS  AND  CONJEC- 
TURES REGARDING  THE  FAUCI AL 
TONSIL. 

Meeting  of  the  American  Laryngological  As- 
sociation, IslSiY  31,  1909,  reported  in  Medical 
Record,  September  25,  1909. 

J.  S.  Gibh  (Philadelphia),  Paper  on  ''Some 
Observations  upon  the  Co7nplete  Extirpation  of 
Diseased  Tonsils,^'  and  Discussions  hy  the  Asso- 
ciation. Gibh  spoke  particularly  with  reference 
to  the  method  followed  with  the  boys  who  entered 
Girard  College. 

"If  it  is  necessary  to  remove  a  tonsil  at  all,  it 
should  be  done  completely.  The  wire  snare  was 
far  more  efficient  than  the  tonsillotome  in  bring- 
ing about  the  described  condition,  viz.:  removal 
of  all  diseased  crypts.  In  ninety  cases  there  is 
a  fever  between  99°  and  101.5°.  In  nine  cases 
in  which  the  friable  nature  of  the  tonsillar  tissue 
was  very  pronounced,  and  in  which  there  was 
much  dissection  and  the  use  of  punch  forceps 
called  for,  the  fever  rose  to  102°  and  over.  In 
two  cases  there  was  regurgitation  of  fluids 
through  the  nose.  The  fauces  were  indurated 
and  there  was  sloughing  over  the  area  of  the  ton- 
sillar wound." 

E.  L.  Shurly  (Detroit)  "commended  the  views 
of  Dr.  Gibb  but  said  that  while  we  were  all 
familiar  with  the  results  of  tonsillotomy,  we 
did  not  know  so  much  about  the  remote  results. 


SIX    MEDICAL   QUESTIONS  I33 

We  must  remember  that  the  tonsil  has  an  inter- 
nal secretion^  and  that  we  do  not  know  the  pos- 
sible results  on  the  pharynx,  stomach  and  con- 
tiguous or  neighboring  organs  following  the  re- 
moval of  all  the  tonsillar  tissue.  Disagreeable 
atrophy  might  ensue.  We  should  indeed  re- 
move all  diseased  crypts,  but  have  we  done 
enough  by  so  doing?  Should  we  not  leave 
enough  tissue  to  perform  the  functions  of  the 
tonsils?'' 

Casselherry  {Chicago)  "did  not  agree  with 
Shurly.  We  should  always  remove  the  tonsil- 
lar tissue  completely.  We  should  be  sure  to 
remove  the  tissue  included  within  the  velum, 
which  he  had  named  the  'velar'  lobe." 

Freer  (Chicago)  "used  sharp  instruments  in 
freeing  the  tonsil  from  its  adhesions." 

Barnhill  (Indianapolis)  said  that  "whatever 
function  the  tonsil  might  have,  there  was  plenty 
of  other  tissue  in  the  throat  which  would  take 
care  of  that  function,  especially  since  the  tonsil 
was  diseased.  The  tonsil  pits  often  filled  up 
after  removal  with  granulation  tissue,  but  some- 
times adhesions  formed  between  the  anterior  and 
posterior  pillars,  and  these  might  pile  up  on  the 
tongue  and  hind  it  down/' 

C.  G.  Coakley  (New  York)  said  that  "there 
had  been  in  his  cases  anywhere  from  two  to  four 
weeks  after  operation  a  small  mass  of  granula- 
tion tissue,  which  he  removed  by  either  the  punch 
or  nitrate  of  silver.  There  was  often  left  an 
irregularity  of  the  lower  edge  of  the  velum  on  the 
two  sides,  and  he  wofidered  what  effect^  if  any, 
followed  in  professional  voice  users/' 


134  THE    TONSILS    AND    THE    VOICE 

G.  Hudson-Mahuen  {Philadelphia)  "thought 
that  one  great  element  of  value  in  GibVs  paper 
was  that  he  had  been  able  to  watch  his  cases  so 
closely  and  report  on  their  condition  some  time 
after  operation.  He  would  as  soon  think  of 
leaving  a  decayed  tooth  root  in  the  mouth  as  to 
leave  a  portion  of  a  tonsil." 

R.  C.  Myles  (New  York)  "called  attention  to 
the  basi-lateral  tonsils  he  had  described  some  fif- 
teen years  before.  He  had  seen  them  extending 
at  least  three-quarters  of  an  inch  into  the  palate, 
and  when  the  entire  capsule  had  been  removed 
there  had  been  a  cellulitis  extending  into  the 
zygomatic  fossa.  Sections  of  the  superior  con- 
strictor muscles  were  too  often  removed  along 
with  the  tonsils."^ 

J.  Price  Brown  (Toronto)  "had  been  told  by 
a  music  teacher  of  that  city  that  several  pupils 
had  their  singing  voices  practically  destroyed  by 
the  removal  of  the  tonsils." 

W.  K.  Simpson  (New  York)  "thought  that 
we  were  too  apt  to  base  our  opinion  on  the  imme- 
diate sequel  following  removal  of  the  tonsils,  and 
that  we  might  get  from  the  filling-up  of  the  ton- 
sillar fossa  with  cicatricial  and  connective  tissue 
an  interference  with  the  muscular  action  of  the 
velum  which  would  he  just  as  harmful  as  the 
leaving  behind  of  a  small  poj'tion  of  the  tonsil." 

J.  O.  Roe  (Rochester)  said  "that  patients 
sometimes  complained  more  of  septic  trouble 
around  the  neck  and  of  glandular  swellings  after 
the  tonsil  operation  than  before  it.  When  a  ton- 
sil was  diseased  it  was  diseased  all  the  way 
through,  for  the  crypts  went  all  the  way  to  the 


SIX   MEDICAL   QUESTIONS  ^     135 

bottom  of  the  tonsil,  and  If  one  left  a  portion  be- 
hind one  had  increased  absorption  of  the  septic 
material  in  the  region." 

E7nil  Mayer  (New  York)  "deprecated  the  use 
of  the  finger.  Modern  surgery  called  for  the 
use  of  rubber  gloves.  He  uses  a  blunt  dissector. 
He  thought  that  too  much  emphasis  had  been 
laid  on  the  amount  of  blood  in  these  regions." 

Meeting  of  the  Societe  Beige  d'Otologie,  de 
Rhinologie  et  de  Laryngologie. 

Reported  in  La  Presse  Oto-Laryngologie 
Beige,  No.  7  of  1910.  A  review  and  discussion 
of  paper  presented  by  Hicguet  on  ''The  Func- 
tions and  Utility  of  the  Palatine.  Tonsils.  Study 
of  the  Physio- pathology  of  that  Organ." 

Hicguet,  "in  presenting  his  paper,  ran  over  in 
a  rapid  resume  the  diverse  theories  held  on  this 
subject  since  those  days  of  Kolliher,  who  does 
not  attribute  to  the  tonsil  any  physiological  role, 
down  to  the  quite  recent  opinion  of  Frederici, 
who  considers  that  organ  as  the  agent  of  elimina- 
tion of  harmful  and  infectious  substances,  a 
function  in  which  the  tonsil  comes  to  the  defense 
of  the  organism.  Hicguet  remarks  that  we 
must  accord  much  more  credit  to  the  work  of  the 
physiologists  than  to  that  of  specialists,  when 
these  latter  constitute  themselves  improvised 
laboratory  operators.  He  reviews  the  work  of 
Stohr  and  Flemming  and  also  the  article  of 
Bickel,  in  which  those  authors  affirm  that  the 
gland  itself  has,  in  total,  little  importance. 

"The  leucocytes,  which  form  in  the  tonsil,  di- 
rect themselves  in  part  toward  the  surface  of  the 
organ:  the  others,  in  a  more  notable  proportion, 


136  THE    TONSILS    AND    THE    VOICE 

pass  by  the  vasa  eff erentia  into  the  general  lym- 
phatic circulation,  and  thereon  into  the  blood. 
It  is,  so  to  speak,  assigning  to  the  tonsil  a  role  of 
defense.  Goerhe,  inspired  by  the  works  of  Brie- 
ger,  has  set  forth  that  latest  theory,  so  much  in 
opposition  to  American  authors,  who  see  in  the 
tonsil  a  mischievous  organ  and  even  dangerous 
to  the  organism  by  reason  of  the  infections  which 
may  be  carried  in  by  that  path.  Brieger's  views 
need  to  be  confirmed,"  said  Hicguet,  "and,"  he 
concludes,  that  "in  the  actual  state  of  our  knowl- 
edge, it  is  very  difficult  to  say  whether  the  normal 
tonsil  is  useful  or  harmful.  Two  theories  remain 
before  us:  the  one  considers  the  tonsil  as  an 
auxiliary  to  the  organic  defense,  and  the  other 
as  a  source  of  infection.  Both  appear  to  him  as 
exaggerated^  for  it  seems  evident  to  him  that  the 
hypertrophied  and  diseased  tonsil  coidd  not  come 
to  the  defense  of  the  organism,  while  the  normal 
tonsil  could  not  be  a  source  of  infection/^ 

Discussion. 

Cheval  "regrets  his  inability  to  come  to  the 
support  of  his  conclusions.  He  put  in  parallel 
the  last  three  paragraphs  with  the  conclusion  of 
the  first  paragraph.  The  author  says,  'The  one 
of  the  two  theories  considers  the  tonsil  as  an  or- 
gan of  defense,'  and  'That  theory  seems  to  apply 
to  the  normal  tonsil';  and  'On  the  other  part,  it 
is  not  possible  to  afiirm  that  the  normal  tonsil  is 
useful  or  harmful.'  It  seemed  to  him  that  Hic- 
guet had  been  able  to  conclude  in  the  afiirmative. 
The  normal  tonsil  is  a  usefid  organ,  because  in 
the  actual  state  of  our  knowledge,  it  is  demon- 


SIX    MEDICAL    QUESTIONS  137 

strated  that  it  comes  to  the  defense  of  the  or- 
ganism. In  his  conclusion,  Hicguet  says 
further:  'While  the  normal  tonsil  could  not  be  a 
source  of  infection.'  Eveii  co7iditionally ,  that 
phrase  is  too  absolute.  In  fact,  aside  from  cer- 
tain humors  which  have  a  bactericidal  power,  the 
defense  of  the  organism  against  infection,  which 
watches  it  at  every  instant,  is  exercised  principal- 
ly by  the  phagocytes.  For  the  7nechanism  of 
infection  does  not  sensibly  differ  from  the  mech- 
anism of  defense:  there  is  not  between  these  two 
mechanisms  but  one  difference,  if  more  or  less. 
In  effect:  (a)  That  the  virulence  of  the  germ 
augments  the  chimiotaxism  of  the  leucocytes,  an- 
nounces to  them  the  presence  of  a  germ  with  its 
infectious  qualities:  there  is  hypopolynucleose ; 
the  polynuclei  desert  the  field  of  battle  and  take 
refuge  in  the  smaller  circulation  and  in  the 
deeper  organs  ( spleen,  etc. ) .  There  is,  in  conse- 
quence, infection  more  or  less  profound :  a  single 
failure  of  the  phagocycloses  may  then  provoke 
an  infection.  To  this  hypopolynucleosis  suc- 
ceeds a  hyperpolynucleosis  which  may  phagocy- 
tose  the  germs  and  avoid  the  diffusion  of  the 
infection;  (b)  the  phagocyte  itself  may  lose  cer- 
tain of  its  properties,  following  a  weakening  of 
the  general  condition;  for  example,  sometimes 
also  from  some  entirely  different  local  cause 
(traumatism,  surgical  intervention,  etc.)  and  the 
germ  then  triumphs, 

"In  other  terms,  the  leucocyte  triumphs  over 
the  microbe  in  the  defense  of  the  organism:  the 
microbe  triumphs  over  the  leucocyte  in  infection. 


138  iHE    TONSILS    AND    THE    VOICE 

and  these  alternatives  may  succeed  each  other 
many  times  in  the  course  of  an  existence. 

"But  at  the  precise  moment  of  this  weakening 
or  failure,  more  or  less  prolonged,  of  our  white 
corpuscles,  the  tonsil  may  appear  normal.  It 
will  be  at  least  in  an  ante-pathologic  condition, 
and  even  normal  in  certain  cases  where  the  germ 
is  not  phagocytosed,  or  only  slightly  so.  From 
this,  can  we  write  that  the  normal  tonsil  cannot 
be  a  source  of  infection? 

"I  thus  approach  the  opinion  of  Broeckaert. 
It  is  evident  that  the  pathologic  tonsil  may  be  a 
source  of  infection  and  has  no  longer  the  power 
of  coming  to  the  defense  of  the  organism;  per 
contra,  in  a  state  of  perfect  health  and  under  ordi- 
nary conditions,  the  physiological  tonsil  has  for 
its  function  the  assisting  in  that  defense.  But 
sometimes,  also,  its  state  of  defense  weakens,  and 
it  may  become  a  source  of  infection." 

Tretrop  "desired  to  make  some  remarks  in  de- 
tail: Infection  through  the  tonsil,  taught  as  an 
hj^pothesis,  is  for  Tretrop  a  realitj^  It  is  not 
astonishing  that  the  tonsil,  a  lymphoid  organ  in 
relation  with  the  sub-adjacent  lymphatic  ways, 
may  become  infected,  and  transmit  farther  on 
this  infection,  without  even  necessarily  becoming 
diseased  on  its  own  account." 

Escat  "addressed  his  compliments  to  Hicguet 
and  Broeckaert  for  their  papers,  so  supported  by 
documents  and  so  precise.  He  is  in  accord  on 
the  majority  of  points  with  these  gentlemen,  but 
nevertheless,  makes  some  remarks." 

Escat  "attaches  a  certain  value  to  the  theory 
oi  Allen  as  to  the  hypothesis  of  a  tonsillar  func- 


SIX    MEDICAL    QUESTIONS  139 

tion  beginning  and  ending  with  the  skeletonic 
growth.  The  fact  that  the  tonsils  normallj''  atro- 
phy from  the  time  that  this  growth  terminates, 
justifies,  to  a  certain  point,  this  hypothesis.  Re- 
searches made  by  Lichtwitz  and  Sabrages  on  the 
modification  of  the  hemotologic  formula  verified 
before  and  after  the  surgical  ablation  of  ade- 
noids, seems  to  justify  the  hypothesis  of  a  dys- 
trophic condition  connected  with  the  alteration 
of  the  internal  secretion  of  the  ring  of  Wald- 
eyer." 

C apart,  Jr.:  "Not  only  the  palatine  and 
pharyngeal  tonsils  atrophy  normally  at  a  certain 
age,  but  it  is  the  same  with  the  lymphatic  tissues 
of  the  digestive  tube,  and  of  the  organism  in 
general.  Also,  it  is  by  an  evident  error  that  we 
see  the  anatomists  describe  in  an  adult  a  palatine 
tonsil  of  an  appreciable  dimension.  It  is  follow- 
ing interior  infections  that  this  organ  loses  the 
possibility  of  self- absorption  at  a  certain  age. 
We  may  recall  in  favor  of  the  hypothesis  of  an 
internal  secretion  of  an  unfavorable  influence, 
the  remarks  made  recently  by  Lermoyez.  'Chron- 
ically inflamed  adenoids  appear  to  lead  to  differ- 
ent troubles  from  those  observed  following  nasal 
obstructions  due,  for  example,  to  atresiae  or  to 
fibrous  polypi.  On  the  other  hand,  the  ablation 
of  adenoids  even  reduced,  often  leads  to  an 
amelioration  not  in  accord  with  the  respiratory 
troubles  which  it  could  bring  on." 

Poli  (Genoa)  spoke  on  "the  theory  of  the  elim- 
ination of  microbes  by  the  tonsil,"  and  was 
supported  by  his  associate,  Frederici.  In  sup- 
port of  that  view,  he  showed  microscopic  prepara- 


140  THE    TONSILS    AND   THE    VOICE 

tions  of  the  tonsil  taken  from  a  dog  in  which 
Frederici  had  injected  into  the  pleura  a  culture 
of  the  bacillus  of  Koch.  The  presence  of  bacilli 
were  perceived  in  the  tonsillar  crypts." 

Schiffers  (Liege) :  "When  we  speak  of  the 
function  of  an  organ,  it  is  necessary  to  consider 
above  all,  its  texture.  That  of  the  tonsil  corre- 
sponds to  the  texture  of  the  lymphatic  ganglions. 
It  acts,  then,  as  they  do.  It  must  be  added  that 
the  tonsils  being  placed  at  the  entrance  of  the 
superior  respiratory  and  digestive  tracts,  and  dis- 
posed all  on  the  surface,  must  also  have  another 
function.  This  is,  according  to  the  author,  a 
function  of  defense.  The  tonsils  are  leucocytic 
organs.  Histological  examinations  show  that 
the  leucocytes  are  derived  from  the  epithelium  of 
the  tonsillar  crypts." 

Hicguet  responds  that  "the  diversity  of  theo- 
ries which  he  has  met  in  his  work  has  put  him  to 
much  pains  to  form  the  conclusions  at  the  end  of 
this  report  and  explains  why  he  is  not  enthusias- 
tic about  any  of  them.  He  supports  in  part  the 
observations  of  Cheval,  but  puts  them  in  opposi- 
tion to  the  opinion  of  Escat,  who  does  not  seem 
to  be  a  partisan  of  the  phagocyte  theory,  and 
who,  on  the  contrary,  accords  a  more  particular 
attention  to  the  theory  of  Allen." 

To  Tretrop,  who  "recalls  that  the  tonsil  is  of- 
ten the  port  of  entry  of  infection,  Hicguet  re- 
sponds that  in  his  paper  he  does  not  consider  this 
fact  hypothetic,  except  in  the  sense  of  the  Amer- 
ican authors,  who  consider  the  tonsils  as  a  dan- 
ger." 

"As  to  the  analysis  of  the  blood,  it  could  not 


SIX    MEDICAL   QUESTIONS  141 

give  serious  results,  except  in  the  case  of   'hos- 
pitalized' patients." 

At  the  same  meeting  of  the  Societe  dfOtolo^e, 
de  Rhinologie  et  Laryngologie,  also  reported  in 
the  La  Presse  Oto-Laryngologie  Beige,  there  was 
a  paper  presented  by  Broeckaert,  entitled,  ''Ad- 
vantages and  Disadvantages  of  the  Ablation  of 
the  Palatine  Tonsils." 

Broeckaert  (Gand),  at  the  beginning  of  his 
paper,  "declares  that  the  theories  proposed  so  far 
do  not  satisfy  him,  and  that,  as  Levinstein  has 
very  justly  remarked,  'The  question  of  the  true 
role  of  the  tonsils  is  yet  to  be  solved.'  In  the 
first  chapter  the  author  examines  the  arguments 
that  may  be  of  value  in  favor  of  the  suppression 
of  the  tonsils;  he  then  studies  the  various  infec- 
tions to  which  the  palatine  tonsils  appear  to  serve 
as  a  port  of  entry;  he  then  describes  the  remote 
troubles  to  which  these  infections  give  rise. 

"The  second  part  of  the  work  is  devoted  to  an 
examination  of  the  disadvantages  resulting  from 
the  ablation  of  the  tonsils,  and  the  measures  to 
be  taken  to  avoid  the  complications  following  that 
operation." 

Discussion. 

Escat  (Toulouse)  is  "completely  in  accord 
with  the  writer  concerning  the  technic  of  the  abla- 
tion of  the  palatine  tonsils.  The  adenoid  tissue 
is  not  neoplastic  tissue:  why  then  be  so  bent 
upon .  extirpating  it  as  radically  as  if  it  were  a 
cancer^  It  is  to  be  feared  that  if  tonsillectomy 
following  the  American  method  becomes  very 
common,  the  cases  of  operatory  hemorrhage  will 


142  THE    TONSILS    AND    THE    VOICE 

multiply  and  that  the  good  reputation  of  tonsil- 
lectomy will  suffer  from  it." 

M.  Delsaux  (Brussels)  "has  paid  attention  to 
two  types  of  tonsils,  very  distinct :  the  simple  hy- 
pertrophic and  the  'enchatoneed  lacunary. 
t^Hiile  the  former  are  rarely  accompanied  by  a 
ganglionic  invasion  of  the  neck,  the  others,  pro- 
foundly infected,  have  transmitted  their  infec- 
tion to  the  IjTuphatic  cervical  barriers.  Thus, 
when  we  remove  the  tonsils  of  the  first  variety,  we 
almost  never  perceive  a  febrile  reaction.  It  is  not 
the  same  with  the  ' enchatoneed'  tonsils,  accom- 
panied by  cervical  ganglionic  swelling.  And  this 
may  be  conceived,  since  the  infection  is  locahsed 
in  the  tonsil,  on  the  one  part,  and  that  on  the  other 
it  has  passed  the  limits  of  the  organ  in  view. 
The  traumatism  of  the  tonsillectomy  exalts  the 
microbian  virulence,  and  the  fever  appears.  Del- 
sauoc  is  supported  by  the  statistics  of  about  fifty 
cases." 

ScMffers  (Liege) :  "When  it  concerns  the  set- 
ting forth  of  therapeutic,  and  above  all,  of  oper- 
atory  conditions,  it  is  necessary  to  consider  the 
normal  and  pathologic  state  of  an  organ.  Evi- 
dently, if  the  tonsil  is  inflamed,  its  function  is 
prejudiced  by  it.  We  must  distinguish  the  true 
from  these  false  hypertrophies.  The  tonsil  of- 
ten retrocedes  because  there  is  no  true  hyper- 
trophy. The  volume  of  a  tonsil  does  not  consti- 
tute an  absolute  indication  for  an  operation.  The 
speaker  has  remarked  this  with  reason.  Accord- 
ing to  ScMffers,  the  tonsillectomy  is  an  operation 
to  be  completel}'-  advised  when  it  concerns  solely 
the  avoidance  of  new  inflammations.     It  is  not 


SIX    MEDICAL    QUESTIONS  143 

imposed,  and  is  not  justified  except  in  cases  of 
malign  tumors  of  the  tonsil.  The  tonsil  itself, 
is,  however,  very  rarely  attacked  by  suppuration : 
there  exist  certainly,  suppurative  follicles,  hut  the 
instertitial  tissue  itself  does  not  suppurate. 
When  we  speak  of  tonsillitis  with  suppuration,  it 
concerns,  in  the  immense  majority  of  cases,  the 
peritonsillitis.  It  is  the  peritonsillar  tissue  which 
forms  the  abscess,  and  most  frequently  it  is  at 
the  superior  pole  of  the  tonsillar  loge  where  the 
pus  must  he  sought.  In  many  cases  of  relapse  it 
is  necessary,  first  of  all,  to  liberate  the  tonsil, 
principally  in  front  and  rear,  which  suffices  to 
definitely  cure  the  patient." 

Broeckaert  (Gand) :  "Thanks  Escat,  Delsauoc 
and  Schiffers  for  the  important  part  they  have 
taken  in  the  discussion  of  his  paper  and  partakes 
completely  of  their  opinion.  In  spite  of  the  elo- 
quent pleading  of  Jacques  in  favor  of  tonsillec- 
tomy with  the  hot  instrument,  Broeckaert  could 
not  come  to  the  support  of  this  mode  of  interven- 
tion, which,  as  Tretrop  has  said,  is  painful  and 
in  no  way  avoids  hemorrhages  and  infections. 

'"One  question  to  which  it  would  be  difficult  to 
respond  is  that  of  knowing  what  is  to  be  under- 
stood by  a  normal  tonsil.  When  does  it  become 
hypertrophied,  and  when  is  it  pathologic?  We 
must  not  forget  that,  even  normal,  the  tonsil  pre- 
sents an  irregular  form  with  innumerable  crypts 
which  are  true  microbian  receptacles.  Two 
points  stand  out  from  this  discussion: 

"1st.  We  are  in  accord  in  admitting  that  there 
are  infectious  ' enchatoneed'  tonsils,  which  are  the 
most  dangerous  and  claim  our  intervention. 


144  THE    TONSILS    AND    THE    VOICE 

"2nd.  Such  intervention,  in  these  cases,  must 
be  radical,  without  falling  into  excesses." 

At  the  same  meeting  of  the  Societe  d'Otologie, 
Jacques  {Nancy)  presented  a  paper  on  the 
"Considerations  on  the  Ablation  of  the  Tonsils" 

"Among  the  multiple  lymphoid  agglomera- 
tions which  are  arranged  along  the  paths  of  the 
air  and  of  the  aliments,  the  palatine  tonsils  par- 
take, with  the  pharyngeal  tonsils,  an  unfortunate 
fragility,  which  translates  itself  by  a  remarkable 
receptivity  in  regard  to  pathogenic  germs  and  a 
consecutive  aptitude  for  hyperplastic  degenera- 
tion. Also  we  should  relegate  to  the  ranks  of  the 
Utopias,  the  seductive  theory  which  makes  of 
these  organs  intangible  citadels  of  the  digestive 
and  respiratory  passages,  though  they  do  not 
constitute,  in  reality,  in  the  greater  number  of 
cases,  more  than  a  double  hearth  of  infection, 
with  continual  menace  of  the  lymphatic  passages. 
Every  tonsil  recognized  as  chronically  inflamed 
should  be  radically  suppressed." 

"The  different  methods  of  partial  amputation 
are  inoffensive  or  dangerous.  The  section  with 
the  hot  instrument,  after  pediculisation  of  the 
gland,  assures  a  rapid  and  complete  excision.  It 
is  exempt  from  danger,  if  it  is  practised  with  a 
wire  moderately  heated,  applied  to  the  exact  lim- 
it of  the  tonsil  and  the  pillars." 

Tretrop  {Antwerp) :  "Tonsillectomy,  the  In- 
dications, the  Results." 

"The  tonsil  is  the  seat  of  local  inflammations, 
and  the  port  of  entry  of  general  infection.  The 
author  has  observed  it  in  tuberculosis,  etc.  The 
chronic    inflammations,    bringing    on    close    ad- 


SIX   MEDICAL    QUESTIONS  145 

hesions  with  the  pillars,  create  a  pseudo-tubercu- 
losis. Tonsillectomy  is  the  chosen  method  in  the 
adult  to  cure  the  old  inflammations  and  the  pseu- 
do-inflammations. Tretrop  passes  in  review  the 
methods  most  employed  and  shows  the  advan- 
tages of  each  of  them.  He  insists  on  the  neces- 
sity of  treatment  preparatory  to  the  interven- 
tion." 

Meeting  of  the  British  Medical  Association, 
Section  of  Larynology,  July  29,  1910,  reported 
in  the  Journal  of  Laryngology,  Rhinology  and 
Otology,  of  October,  1910.  A  paper  presented 
by  Dan  MacKenzie,  on  ''Enucleation  of  the  Ton- 
sil";  and  the  discussion  by  members  of  the  Asso- 
ciation. 

"Complete  and  entire  removal  of  the  hpyer- 
trophied  tonsil  by  dissecting  it  out  of  its  bed  in 
the  pharynx  has  come  to  be  the  operation  de 
rigueur  in  America.  Those  who  advocate  enu- 
cleation as  the  routine  operation  summon  logic  to 
their  aid. 

"If,  they  say,  it  is  improper  in  the  surgical 
sense  not  to  remove  the  whole  of  a  lymph  node 
or  nodes  when  they  are  diseased,  in  the  neck  or 
elsewhere,  then  surely  it  is  equally  improper  to 
treat  an  enlarged  tonsil — which  is,  after  all,  a 
lymph  node — by  partial  excision,  seeing  that  in 
doing  so  we  leave  behind  undisturbed  a  certain 
amount  of  diseased  gland  tissue.  At  first  sight 
this  argument  looks  unassailable,  but  it  rests 
upon  an  assumption — namely,  that  an  enlarged 
tonsil  is  invariably  a  diseased  tonsil.  Compari- 
son of  the  enlarged  tonsil  with  the  enlarged  lym- 
phatic gland  of  chronic  tuberculosis  is  not  quite 
11 


146  THE    TONSILS    AND    THE    VOICE 

accurate.  For,  as  it  is  well  known,  no  patholo- 
gist has  so  far  succeeded  in  proving  to  the  satis- 
faction of  all  that  ordinary  hypertrophy  of  the 
tonsils  is  general^,  or  frequently,  or  ever  at  all, 
due  to  tuberculous  infection  such  as  that  which  so 
often  induces  chronic  cervical  adenitis.  In  op- 
position to  the  opinion  which  would  lead  us  to 
take  up  enucleation  as  the  routine  operation  for 
hypertrophy  of  the  tonsil,  we  can  point  to  the 
fact  that  the  ordinary  tonsillotomy  efficiently 
performed  is  seldom  followed  by  a  recurrence  of 
the  hypertrophy. 

"There  is  no  doubt  whatever  that  enucleation 
is  the  more  severe  operation;  it  takes  longer  to 
perform;  it  inflicts  a  deeper  and  more  extensive 
wound. 

"Is  there  a  class  of  cases  in  which  enucleation 
is  to  be  preferred  to  tonsillotomy  or  the  typical 
operation?  I  think  there  is.  Enucleation 
should  always  he  performed  when  the  tonsil  is 
diseased  and  not  merely  hypertrophied.  Second- 
ly, the  tonsils  should  be  enucleated  in  patients 
who  are  suffering  from  tuberculous  disease  of 
the  cervical  lymphatic  gland.  There  is  another 
variety  which  should  be  dealt  with  by  complete 
removal.  I  refer  to  what  is  known  as  the 
'buried'  tonsil.  One  would  be  very  cautious  of 
recommending  enucleation  to  a  professional 
singer,  for  obvious  reasons." 

Discussion. 

St.  Clair  Thomson  said:  "The  operation  de- 
scribed hy  Dan  McKenzie  was  no  new  depar- 
tiu-e.     It  was  as  old  as  Celsus,  and  he  himself 


SIX    MEDICAL    QUESTIONS  147 

had  published  a  method  of  enucleating  the  tonsil 
many  years  ago." 

Dundas  Grant  said  that  "he  exercised  a  cer- 
tain amount  of  eclecticism  in  the  choice  of  opera- 
tion. He  considered  that  the  leaving  of  a  portion 
of  tonsil  tissue,  as  such,  was  not  a  serious  matter 
and  indeed  possibly  a  beneficial  one  so  long  as 
the  crypts  were  cleared  away.  Moreover,  the 
protective  character  of  the  capsule  had  already 
been  pointed  out,  and  its  complete  removal  was 
open  to  question." 

Luc  said:  "The  wire  snare  was  a  troublesome 
instrument  to  use,  and  recommended  in  its  stead 
the  so-called  'rigid  cold  snare'  of  Vachez." 

Watson  Williams  asked:  "What  definite  in- 
formation did  we  possess  regarding  the  physiol- 
ogy of  the  tonsils?  In  rheumatism,  which  had 
been  ascribed  to  tonsillitis,  he  had  frequently 
found  the  tonsils  atrophied  or  absent.  He  did 
not  think,  therefore,  that  enucleation  was  the  best 
operation,  but  the  question  was  one  which  re- 
quired thrashing  out." 

Lambert  Jack  held  that  "enucleation  should 
never  be  the  routine  operation.  Removal  of  the 
tonsils  by  the  guillotine  in  the  hands  of  a  skilled 
operator  gave  results  as  good  as  any  other  opera- 
tion. The  need  of  getting  every  crypt  away  was 
exaggerated.  The  throat  has  many  crypts  and 
to  remove  them  all  would  be  impossible.  Mr. 
Hetfs  statistics,  referring  as  they  did  to  hospital 
cases,  were  fallacious,  because  at  hospitals  the 
operation  was  most  incompletely  performed." 

Syme  said  that  "Enucleation  was  not  neces- 
sary in  every  case." 


148  THE    TONSILS    AND    THE    VOICE 

TV.  Stuart-Low  thought  that  ''Enucleation 
was  best  suited  for  adults  with  large  tonsils  and 
not  for  children.  He  feared  that  Hett  removed 
muscle  as  well  as  tonsil  in  operating." 

Seccomhe  Hett  said  that  "If  Stuart-Low 
charged  him  with  removing  muscle,  his  reply  was 
that  Stuart-Low  left  the  capsule  behind." 

Dan  McKenzie  in  reply  said  that  "The  discus- 
sion had  revealed  considerable  discrepancy  of 
opinion  with  regard  to  the  best  way  to  operate. 
It  also  showed  that  the  principles  laid  down  in 
his  paper  with  regard  to  enucleation  in  disease 
and  recurrent  hypertrophy  had  received  a  gen- 
eral assent." 

The  president,  H.  Tilley,  said  that  "the  trend 
of  opinion  seemed  to  be  that  the  cases  should  be 
selected  for  each  operation." 

Seccomhe  Hett  {Meeting  of  British  Medical 
Association,  July  29,  1910.  Reports  in  Journal 
of  Laryngology,  Rhinology  and  Otology,  Octo- 
ber, 1910) .  "The  Anatomy  of  the  Capsule  of 
the  Tonsil  and  Its  Significance  in  the  Treatment 
of  Diseases  of  the  Tonsil" 

Describing  the  anatomy  of  the  tonsillar  cap- 
sule, Hett  "observed  that  the  upper  portion  is 
surrounded  by  a  loose  areolar  tissue  space,  the 
peritonsillar  space,  which  is  limited  below  by  the 
insertion  of  muscular  fibres  from  the  superior 
pharyngeal  constrictor  into  the  capsule.  In  the 
act  of  swallowing,  the  upper  part  of  the  tonsil  is 
pressed  downward  and  inwards  between  the  pil- 
lars in  such  a  way  as  to  encourage  the  discharge 
of  secretions  from  the  supra-tonsillar  fossa." 

Meeting  of  the  American  Laryngological  As- 


SIX   MEDICAL   QUESTIONS  149 

sociation.  May  30,  1911,  reported  in  the  New 
York  Medical  Record  of  September  16,  1911. 
Report  of  paper  presented  by  Henry  L.  Swain 
{New  Haven)  on  ''Are  Tonsils  a  Menace  or  a 
Protection?"^  and  the  discussion  by  members  of 
the  Association. 

Swain  discussed  the  question  as  answered, 
"First,  in  the  practice  of  throat  surgeons  all  over 
the  country.  As  they  almost  universally  were 
adopting  the  operation  of  tonsillectomy  when- 
ever they  attacked  the  tonsils,  the  inference  was 
that  the  latter  were  surely  of  account  and  always 
a  menace.  Answering  the  question  from  the 
anatomical  and  physiological  standpoint,  the  evi- 
dence adduced  was  such  that  it  could  be  readily 
proved  that  the  tonsil  was  to  all  intents  and  pur- 
poses a  lymph  node  and  was  of  just  as  much  im- 
portance, no  more,  no  less,  as  any  other  node. 
He  called  attention  to  the  fact  that  the  tonsils 
(faucial)  had  lymphatic  trunks  leading  into 
theiUj,  which  drained  from  the  nose  and  palate, 
so  they  had  a  very  definite  office  in  caring  for  this 
lymphj,  a  very  different  viewpoint  from  the  usual 
one' of  being  a  mere  retentive  area  for  matter 
soaking  into  them  from  the  mouth.  Being  thus, 
when  in  health,  an  active  agent  of  protection  to 
the  system,  the  tonsil  must,  like  the  whole  lym- 
phatic system,  be  of  relatively  greater  importance 
to  the  very  young  child  than  to  the  adult.  These 
two  facts  were  strengthened  by  the  additional 
observation  that  as  the  healthy  normal  individual 
always  had  such  tissue,  which  began  to  function- 
ate early  in  life  in  the  adenoid  tissue  in  the  naso- 
pharynx, in  the  faucial  tonsils,  in  childhood,  and 


150  THE    TONSILS    AND    THE    VOICE 

in  the  lingual  tonsil  in  later  adult  life,  it  would 
seem  absolutely  jjroved  that  the  body  required 
some  such  physiological  action  of  some  such  tis- 
sue for  its  proper  development  or  in  its  economy, 
i.e.:  a  definite  function  for  lymphoid  tissue. 
Taking  this  as  true,  it  would  be  absolutely  illogi- 
cal to  remove  any  of  it  except  for  just  cause,  and 
this  led  Swain  to  deplore  tonsillectomy,  complete 
removal  of  the  tonsils,  as  an  indiscriminate  rou- 
tine procedure  in  young  children,  especially  when 
this  was  accompanied  by  complete  adenoidec- 
tomy.  The  adenoidectomy  was  to  be  com- 
mended— too  thorough  an  operation  was  rarely 
possible — but  in  early  childhood  a  portion  of  the 
healthy  f  aucial  tonsil  tissue  could  be  well  allowed 
to  remain.  The  system  might  have  need  of  it. 
When  diseased,  any  of  the  good  operations  for 
tonsillectomy  could  be  used,  but  he  felt  that  the 
teaching  should  be  that,  even  in  adults,  there 
were  other  methods  of  bringing  about  a  satisfac- 
tory and  safe  condition  of  the  tonsils.  These 
latter  he  almost  universally  employed  by  prefer- 
ence and  such  patients  had,  at  least,  the  benefit  of 
Avhatever  protection  the  saved  tissue  could  be  to 
them." 

Discussion. 

George  B.  Wood  (Philadelphia)  "objected  to 
the  views  held  by  the  essayist,  and  stated  that  he 
had  proved  the  lymph  flow  in  the  tonsil  an  effer- 
ent current.  He  did  not  believe  it  to  be  possible 
to  tell  macroscopically  a  diseased  tonsil.  He  ad- 
vocated in  all  diseased  conditions  the  complete 
removal  of  the  tonsil." 


SIX    MEDICAL    QUESTIONS  151 

J.  G.  Wilson  (Chicago)  "agreed  with  Dr. 
Swain  that  the  physiological  activity  of  the  tonsil 
was  principally  confined  to  fetal  and  infant  life, 
but  did  not  consider  it  as  a  pure  lymphatic 
gland." 

W.  E.  Casselherry  {Chicago)  said  "he  had 
never  seen  a  particle  of  detriment  to  either  the 
child  or  adult  resulting  from  the  total  excision 
of  the  tonsil,  but  explained  this  on  the  basis  that 
there  were  supplementary  tissues  to  continue  its 
functions.  He  agreed  with  Swain  that  during 
childhood  the  tonsils  should  never  be  removed 
unless  definitely  diseased,  but  advocated  their 
absolute  removal  if  operated  upon  at  all." 

John  N.  Mackenzie  (Baltimore)  "emphat- 
ically voiced  his  disapproval  of  the  indiscriminate 
removal  of  tonsils  so  largely  practiced  at  the 
present  time,  and  considered  it  the  duty  of  every 
laryngologist  to  make  the  conditions  warranting 
tonsillectomy  plain  to  the  general  practitioner." 

C.  G.  Coakley  (New  York)  "called  attention 
to  the  fact,  also  referred  to  by  Swain,  that  the 
tonsils  in  children  and  in  adults  were  entirely  dif- 
ferent in  function;  in  adult  life  it  was  classed 
more  as  a  pathological  than  as  a  physiological 
organ.  He  mentioned  the  fact  that  frequently 
in  adults  with  rheumatic  diathesis  the  removal  of 
the  tonsil  which  has  caused  quinsy,  etc.,  would 
show  an  abeyance  of  these  peculiar  manifesta- 
tions. It  was  his  opinion  that  tonsils  should  be 
enucleated  and  not  cut  off,  and  his  experience 
had  been  that  the  children  in  whom  this  pro- 
cedure had  been  carried  out  because  of  disease  of 


152  THE    TONSILS    AND    THE    VOICE 

the  tonsils,  as  a  general  rule  became  markedly 
improved  in  health  following  the  operation," 

A.  Coolidge,  Jr.  (Boston)  "discussed  the  etiol- 
ogy of  acute  tonsillitis,  referring  to  the  recent 
epidemic  in  Boston,  which  was  at  first  traced  to 
the  milk  supply,  but  later  became  general 
throughout  the  city.  He  considered,  in  view  of 
the  mode  of  onset,  that  the  condition  in  the  tonsil 
pointed  rather  to  an  efferent  than  to  an  afferent 
flow  of  the  septic  micro-organisms  or  their 
toxins." 

B.  R.  Shurly  {Detroit)  "deprecated  the  re- 
moval of  tonsils  unless  proved  to  be  diseased.  In 
many  hundreds  of  tonsillectomies  he  had  seen 
nothing  but  favorable  results." 

Bliss  {Philadelphia)  "considered  the  stumps 
of  tonsils  remaining  after  partial  removal  to  be 
a  great  menace  to  the  health  of  the  individual." 


SIX    MEDICAL    QUESTIONS  153 

LETTER  OF  MOURE. 

Translation. 

Question  1.  I  consider  that  the  normal  tonsils 
have  physiologic,  biologic,  chemical  and  pho- 
netic functions. 

There  is  no  doubt  that  they  are  the  advanced 
sentinels  of  the  rear  throat  defending  the  en- 
trance of  the  upper  and  lower  air  passages. 

They  do  not  appear  to  play  an  important  pha- 
gocytic role,  from  a  biological  point  of  view. 

From  a  phonetic  point  of  view,  their  normal 
role  must  evidently  be  to  prevent  in  a  certain 
measure  the  nasality  by  maintaining  the  pillars, 
in  the  midst  of  which  they  are  placed. 

Question  2.  What  I  have  said  above  contains 
the  response  to  the  second  question. 

Question  3.  It  is  difficult  to  say  what  are  the 
effects  of  allowing  the  ablation  of  the  tonsils  in 
view  of  the  fact  above  all,  that,  at  least  in  our 
country,  the  complete  ablation  is  never  per- 
formed, but  only  a  removal  more  or  less  complete 
and  that  in  consequence  there  always  remains 
enough  follicles  to  fulfill  the  role  devolving  on 
that  gland,  which,  like  the  greater  part  of  the 
lymphatic  organs,  atrophies  little  by  little  with 
age. 

Question  4.  After  the  ablation  of  the  tonsils  a 
change  of  the  voice  is  above  all  observed  when  the 
subject  has  already  been  accustomed  to  singing 
and  that  in  consequence  he  has  habituated  himself 
to  emit  the  voice  with  the  two  tonsils  situated  be- 
tween the  pillars. 

If  the  forms  of  certain  hypertrophied  tonsils 


154  THE    TONSILS    AND    THE    VOICE 

embarrass  the  speaking  voice  (phonation),  there 
is  no  doubt  that  there  is  then,  after  their  removal, 
a  very  appreciable  modification  in  the  emission  of 
the  speaking  voice  among  young  persons. 

Question  5.  I  believe  that  in  a  general  way, 
one  should  not  remove  the  tonsils  when  they  are 
not  of  excessive  size,  or  are  not  inflamed;  in  a 
word,  that  they  are  not  the  point  of  departure  of 
local  infection,  frequent  or  distant  (caseous,  sup- 
purative tonsilitis).  They  are  organs  as  useful 
as  the  ganglions  when  these  latter  are  not  degen- 
erated. 

(Signed)   Moure. 

Bordeaux,  January  28,  1910. 


SIX    MEDICAL    QUESTIONS  155 

Question  Number  Two. 

What  are  the  functions  of  the  f aucial  tonsils  ? 

Answers : 

Eugene  Hodenpyl:  "Unknown." 
A.  Coolidge,  Jr.:  "I  do  not  know." 
G.  Hudson-Makuen:  ''I  do  not  know/' 
H.  Holhrook  Curtis:    "To  prevent  the  am- 
nionic fluid  entering  the  respiratory  tract  by  pre- 
natal coalescence  with  the  pharyngeal  and  lingual 
tissues  constituting  the  ring  of  Waldeyer." 

Edwin  Pynchon:  "I  am  disposed  to  think  that 
they  have  no  function  except  to  cause  trouble, 
evidenced  by  the  invariable  improvement  in  one 
way  or  another  after  their  complete  and  correct 
removal.  If  they  have  any  function,  nature  evi- 
dently supplies  other  means  to  fully  and  easily 
take  their  place,  therefore  the  system  sufl*ers  no 
disadvantage  from  their  loss." 

William  E.  Casselherry:  "The  adoption  of 
tonsillectomy  as  the  ideal  operation,  even  though 
the  ideal  be  not  always  exactly  fulfilled,  lends 
more  importance  to  the  inquiry  with  respect  to 
the  protective  and  other  functions  of  the  tonsils. 
The  tonsillar  crypts  always  contain  pathogenic 
germs  against  which  nature  seeks  to  provide  by 
phagocytosis,  the  engaging  polynuclear  neutro- 
philes,  however,  coming  not  from  the  lymphoid 
tissue,  per  se,  but  from  the  blood,  so  that  this  is  a 
protection  only  against  the  evil  of  the  tonsils 
themselves.  More  stress  is  now  laid  upon  the 
bactericidal  properties  of  the  juice  of  lymphoid 
glands  and  upon  the  vaso-tonic  effects  of  an  in- 


156  THE   TONSILS   AND   THE   VOICE 

ternal  secretion,  but  it  will  be  remembered  that 
aside  from  the  tonsils  there  are  other  lymphoid 
tissues  which  seemingly  are  quite  adequate  to 
care  for  these  functions.  Certain  it  is  that  no 
functional  ill  effects  are  discernible  from  tonsil- 
lectomy." 

George  B.  Wood:  "See  answer  to  question 
one." 

Charles  H.  Knight:  "1  do  not  know." 

J.  E.  Newcomb:  "I  believe  that  the  normal 
tonsil  is  the  origin  of  cells,  phagocytes,  to  take 
care  of  deleterious  substances  introduced  into  the 
mouth." 

Joseph  W.  Gleitsmann:  "I  believe  the  tonsils 
to  be  an  organ  for  defense  (Goerhe,  Archiv.  fiir 
Laryngologie  XIX,  1907,  page  244),  {Jonathan 
Wright,  New  York  Medical  News,  March  4, 
1905),  {Brieger,  Archiv.  fiir  Laryngologie, 
XII,  1902,  page  2500)." 

George  B.  Rice:  "I  beheve  that  the  lymphoid 
ring  in  a  normal  state,  including,  of  course,  the 
faucial  tonsils,  has  a  protective  function.  The 
conclusions  of  many  observations  would  seem  to 
warrant  this  belief." 

E.  B.  Gleason:  "They  are  lymphatic  glands. 
Aside  from  the  functions  of  similar  structure,  I 
am  not  prepared  to  give  an  unqualified  endorse- 
ment to  any  of  the  somewhat  numerous  theories 
as  to  the  functions  of  the  tonsils." 

Wesley  Mills :''l  think  likely:  (1)  absorption, 

(2)  possibly  they  furnish  an  internal  secretion, 

(3)  they  may  act  as  elaborators  of  white  blood 
cells." 


SIX   MEDICAL    QUESTIONS  157 

George  L.  Ross:  "This  is  covered  by  question 
number  one." 

St.  Clair  Thomson:  "I  think  this  function  is  a 
protective  one  in  early  childhood,  possibly  only 
up  to  the  completion  of  the  first  dentition.  The 
tonsils  may  defend  the  organism  from  the  risks 
attendant  on  a  small  child's  omniverous  tastes." 

J.  Maclntyre:  "See  answer  to  question  num- 
ber one." 

E.  M.  Holmes:  "I  am  of  the  opinion  that  one 
important  function  of  the  tonsil  (faucial)  is  that 
of  a  very  active  lymphatic  gland,  acting  (as  a  fort 
and  battlefield)  against  infection  arising  in  upper 
air  tracts.  We  have  all  seen  many  attacks  of 
marked  activity  in  the  tonsils  after  injury  to  nose 
(operative  or  other)  and  I  am  at  present  study- 
ing the  frequent  cervical  adenitis  following  these 
causes  where  there  is  no  faucial  tonsil.  The  re- 
sults of  my  studies  thus  far  are  really  very 
marked." 

John  Mackenzie:  "I  do  not  know." 

William  G.  MacCallum:  "Probably  to  act  as 
guards  against  infection — to  abort  and  destroy 
infectious  agents.  Obviously  little  is  known  as 
to  the  exact  function  of  the  tonsils,  but  they  ap- 
parently form  part  of  the  lymphoid  apparatus 
distributed  throughout  the  digestive  tract,  and 
are  comparable  to  the  Peyer's  patches,  etc." 

Frank  E.  Miller:  "Lubrication  principally. 
If  tonsils  are  entirely  cut  out  with  capsule  and 
adjacent  glands,  there  will  be  glandular  secre- 
tions from  the  pharynx,  base  of  the  tongue  or 
back  of  pharynx." 

A.  Barth:  "Secretory  and  resorptive  action. 


158  THE    TONSILS    AND    THE    VOICE 

The  latter  action  is  germicide  ( protective  against 
infection)  but  under  circumstances  leads  to  local 
and  general  infection." 

Luc:  "Same  answer  as  to  question  number 
one." 

Castex:  "The  palatine  tonsils  have  not  ap- 
peared to  me  to  have  any  other  function  than  that 
of  the  other  superior  vascular  glands  of  the  body 
(lymphatic  ganglions,  etc.)." 

Moure:  "What  I  have  said  in  response  to  the 
preceding  question  contains  the  answer  to  ques- 
tion number  two." 

Escat:  "I  am  of  the  opinion  in  accord  with 
Allen,  that  the  tonsils  (palatine,  lingual,  tu- 
baire)  secrete  a  principle,  the  nature  of  which  it 
has  been  unable  as  yet  to  determine,  but  which 
should  be  useful  in  the  development  and  to  the 
growth  of  the  subject,  and  probably  to  the 
growth  of  the  skeleton.  I  have  found  a  reason 
for  this  in  the  fact  that  the  normal  tonsils  atro- 
phy normally  about  the  age  of  eighteen  to  twenty 
j^ears,  from  the  time  that  the  subject  has  become 
fully  an  adult.  This  normal  atrophy  is  manifest 
and  striking  for  the  pharyngeal,  tub  aire  and  lin- 
gual tonsils ;  it  is  more  defaced  and  more  dissimu- 
lated in  the  faucial  tonsils  by  reason  of  their 
globate  form ;  this  is  why,  in  spite  of  the  atrophy, 
there  always  persists  a  small  nut  or  nucleus,  but 
this  atrophied  tonsil  is  nothing  but  a  stump  of 
a  tonsil ;  when  that  atrophied  tonsil  has  conserved 
in  the  adult,  a  certain  grandeur  (groneur),  it  is 
because  it  is  sick :  it  is  because  the  chronic  inflam- 
mation has  counteracted  the  physiologic  atrophic 
involution." 


SIX    MEDICAL    QUESTIONS  159 

M asset:  "I  do  not  give  great  importance  to 
the  opinion  according  to  which  the  faucial  tonsils 
may  render  easier  deglutition,  nor  I  think  suf- 
ficiently demonstrates  that  they  are  glands  of 
internal  secretion." 

Van  Bag  gen:  "For  my  answer  to  this  ques- 
tion see  the  first  answer." 

Von  Chiari:  "Formation  of  leucocytes,  es- 
pecially in  children." 


160  THE    TONSILS    AND    THE    VOICE 

Question  Number  Three. 

What  effects  have  you  observed  as  being  di- 
rectly due  to  the  removal  of  the  faucial  tonsils? 

Answers : 

H.  Holhrook  Curtis:  "Only  good  effects." 
G.  Hudson-Makuen:  "Only  good  effects." 
A.  Coolidgej,  Jr.:  "No  serious  injurious  ef- 
fects." 

George  B.  Wood:  "I  have  never  seen  any  bad 
effects  from  the  removal  of  the  faucial  tonsils." 
Edwin  Pynchon:  "After  twenty  years'  expe- 
rience, covering  at  least  3,000  cases,  I  have  never 
observed  any  other  than  favorable  effects,  aside 
from  temporary  inconvenience  after  the  opera- 
tion.- The  general  health  has  always  been  im- 
proved, only  exceptions  are  question  four." 

William  E,  Casselherry:  "No  evil  effects, 
only  good.  Total  tonsillectomy  has  been  my 
practice  for  a  period  of  j^ears  long  antedating 
our  present  more  technical  method,  and  I  have 
recorded  statistically  the  immediate  and  ultimate 
results  from  a  total  of  600  double  operations 
upon  private  patients,  among  whom  are  relatives, 
friends  and  acquaintances,  together  with  other 
patients  re-examined  years  aftenvard,  for  a  con- 
siderable number  whom  I  have  been  able  to  ascer- 
tain the  last  state  of  the  patient.  In  none  has 
any  harm  resulted,  in  many  inestimable  good.  In 
none  did  I  have  any  reason  to  regret  having  made 
total  tonsillectomy,  my  sole  regret  having  been 
on  account  of  those  cases  in  which  a  remnant  of 
tonsil  had  escaped  removal." 


SIX   MEDICAL    QUESTIONS  161 

Charles  H.  Knight:  "Improvement  in  general 
and  local  conditions,  voice  resonance  and  breath- 
ing, subsidence  of  glandular  swellings,  etc." 

Beverly  Robinson:  "When  advisedly  done — 
many  and  good." 

George  B.  Rice:  "The  enucleation  of  patho- 
logic tonsils  in  my  experience  is  followed  by  less 
frequent  sore  throats,  improvement  in  the  speak- 
ing and  singing  voice,  and  a  change  for  the  better 
in  the  general  health." 

J,  E.  Newcomh:  "Improved  breathing  and 
lessened  liability  to  sore  throats." 

Joseph  E.  Gleitsmann:  "No  deleterious,  only 
beneficial  ones." 

E.  B.  Gleason:  "From  the  removal  of  hyper- 
trophied  or  diseased  tonsils  improvement  in  the 
voice  and  hearing  when  there  was  middle  ear  ca- 
tarrh, usually  also  improvement  in  the  general 
health." 

Eugene  Hodenpyl:  "In  pathological  tonsils 
the  usual  well-known  improvement  ensues." 

Wesley  Mills:  "None  that  were  unfavorable." 

George  L.  Ross:  "Healthy  and  unimpaired 
action  of  the  oro-pharynx,  freedom  from  the  pre- 
vious mechanical  impediment  of  hypertrophy 
and  in  atrophic  cases  relief  from  suffering 
(though  this  is  not  invariable) ." 

John  N.  Mackenzie:  "I  cannot  recall  a  high 
fatality  or  serious  complication  after  tonsil- 
lotomy in  all  the  years  of  my  experience ;  in  suit- 
able cases  it  is  always  productive  of  good,  and 
'when  properly  done  is  practically  just  as  effec- 
tive as  tonsillectomy  *.  neither  can  ever  be  absolute- 
ly complete;  but  the  risks  of  tonsillotomy  are  as 

12 


162  THE    TONSILS    AND    THE    VOICE 

nothing  compared  with  the  accidents  which  fol- 
low tonsillectomy,  to  say  nothing  of  its  long  roll 
of  death." 

J.  Maclntyre:  "Question  three  is  an  exceed- 
ingly difficult  one  for  me  to  answer  because  you 
refer  to  faucial  tonsils  without  any  reference  to 
naso-pharynx,  lingual  tonsils  or,  indeed,  to  the 
adenoid  tissue  in  the  nose  and  throat.  I  would 
find  it  very  hard  to  make  any  observations  upon 
the  faucial  tonsils  alone.  The  same  remark  ap- 
plies to  question  four." 

St.  Clair  Thomson:  "The  usually  noted  and 
well-recognized  improvement  in  health." 

E.  M.  Holmes:  "A  much  larger  percentage 
of  cervical  adenitis  following  nasal  and  naso- 
pharyngeal infection." 

Massei:  "Improvement  of  voice  (when  en- 
larged) ;  improvement  of  general  health  (when 
representing  the  mechanical  impairment  to  the 
free  respiration)  ;  less  occasion  to  sore  throat  or 
infections  which  may  originate  from  that  point." 

Luhet-Barbon:  "I  have  never  observed  any 
troubles  from  the  removal  of  the  tonsils." 

Luc:  "I  generally  observed  diminution  or  sup- 
pression of  the  symptoms  due  to  the  hypertrophy 
of  the  glands." 

Moure:  "It  is  difficult  to  say  what  are  the  ef- 
fects following  the  ablation  of  the  tonsils  in  view 
of  the  fact  above  all,  that  at  least  in  our  country, 
the  complete  'amygdalectomie'  (extirpation)  is 
never  performed,  but  only  a  removal  more  or  less 
complete,  and  that  in  consequence  there  always 
remains  enough  follicles  to  fulfill  the  role  devolv- 
ing on  that  gland,  which,  like  the  greater  part  of 


SIX    MEDICAL    QUESTIONS  163 

the  lymphatic  organs,  atrophies  little  by  little 
with  age." 

Casteoc:  "I  have  never  observed  any  but  good 
results  to  the  condition.  I  do  not  interfere  with 
the  anterior  or  posterior  pillars." 

Escat:  "I  have  observed  nothing  but  good  ef- 
fects— amelioration  of  the  general  condition, 
exaggeration  of  development  in  the  child.  I 
attribute  the  good  result  as  much  to  the  cessation 
of  physiologic  troubles  resulting  from  the  vicious 
internal  tonsillary  secretion  from  the  chronic  in- 
flammation, as  to  the  cessation  of  the  mechanical 
interference  brought  on  by  the  hypertrophy — no 
cacheocia  tonsilliprive  has  been  observed  because, 
even  in  the  most  radical  ablation  of  the  tonsils, 
there  is  always  left  a  little  adenoid  tissue." 

A.  Barth:  "Rarely  any,  always  a  bleeding 
easily  subdued.  Once  a  necrosis  progressive, 
which  yielded  to  antiseptic  washings.  Often 
weak  children  recover  quickly.  Scrofulus  habi- 
tus disappears.  Same  thing  in  removing  pharyn- 
geal tonsils." 

Frank  E.  Miller:  "All  effects  due  to  abnor- 
mal mucous  membrane  thus  affected." 

Schmiegelow:  "When  I  remove  faucial  tonsils 
it  is  always  because  they  are  diseased  or  inclined 
to  be  affected  with  tonsillar  angina;  and  the  re- 
moval has  always  prevented  new  attacks;  other 
effects  I  have  not  seen." 

Van  Baggen:  "Only  in  two  cases  during  my 
experience  of  eight  years  the  removal  of  the  fau- 
cial tonsils  was  necessary.  In  both  cases  the  ton- 
sils were  of  abnormal  size.  In  one  of  those  two 
cases  there  was  no  regular  movement  of  the  soft 


164  THE   TONSILS    AND    THE    VOICE 

palate  and  of  the  pillars  of  the  fauces ;  especially 
when  forming"  the  initial  vocals  a  spasmodic  con- 
traction of  those  parts  took  place,  whereby  the 
swollen  tonsils  were  strongly  protruded.  Every 
attempt  to  correct  the  action  of  the  muscles  of 
the  soft  palate  and  the  pillars  of  the  fauces  re- 
mained without  any  results  because  of  this  pro- 
jection of  the  tonsils.  After  their  removal,  the 
desired  effect  was  obtained  by  carefully  applied 
exercises." 

Von    Chiari:  "The    pharynx    will    be    more 
roomy," 


SIX   MEDICAL   QUESTIONS  165 

LETTER  OF  VON  CHIARI. 

Translation. 

(1)  The  tonsils  most  probably  serve  the  pur- 
pose of  forming  leucocytes. 

(2)  Formation  of  leucocytes,  especially  in 
children. 

(3)  The  pharynx  will  be  more  roomy. 

(4)  If  in  older  mammals  very  large  tonsils 
which  have  very  much  stretched  the  palatine 
arches  have  been  removed  to  the  bottom  of  the 
sinus-tonsillaris,  the  arches  then  lose  their  prop 
and  on  account  of  the  relaxing  of  the  muscles  of 
the  arches  they  cannot  thereafter  contract  ef- 
ficiently. Therefore,  the  resonance  of  the  throat 
gets  flabby  walls,  so  that  the  strength  and  fulness 
of  the  tones  suffer. 

(5)  No. 

(6)  You  will  find  a  new  detailed  summary  of 
my  remarks  in  the  book  called: 

Die  Krankheiten  des  Rachens, 

Von  O.  Chiari 

Leipzig  und  Wien, 

Franz  Denticke, 

1903. 

Yours  truly, 
(Signed)   O.  Chiari. 
Vienna,  18th  October,  1910. 


166  THE    TONSILS    AND    THE    VOICE 

Question  Number  Four. 

Have  you  noted  phonetic  changes  after  the  re- 
moval of  the  faucial  tonsils? 

Answers : 

H.  Holbrook  Curtis:  "Always  improves  the 
clearness  of  tone  and  lessens  vocal  fatigue." 

G.  Hudson-Makuen:  "Yes,  changes  for  the 
better." 

A.  Coolidge„  Jr.:  "No  important  ones,  except 
in  adult  singers,  who  in  one  or  two  cases  partially 
lost  delicate  control.  This  would  have  been  un- 
important to  anyone  else." 

Edwin  Pynchon:  "When  properly  done  with 
proper  after  treatments  to  prevent  growth  of 
exuberant  granulation  tissue,  the  effect  has 
always  been  favorable,  increasing  the  vocal  range 
of  singers  and  correcting  former  tendency  to 
hoarseness  when  such  existed  either  in  singers  or 
speakers,  as  lawyers,  etc.  When  proper  after 
treatments  are  neglected  a  new  growth  of  tissue 
may  interfere  with  free  motion  of  the  pillars  and 
soft  palate,  though  this  has  occurred  rarely  and 
the  effect  on  the  voice  has  been  slight." 

William  E.  Casselherry:  "In  no  instance  has 
any  ultimate  harm  resulted  from  the  operation; 
nothing  but  good.  Lambert  Lack  reports  a  case 
of  loss  of  singing  voice.  My  series  includes  but 
eight  prominent  vocalists  and  perhaps  an  equal 
number  of  public  speakers,  in  all  of  whom  the 
voice  was  improved,  but  the  number  would  be 
larger  were  it  not  that  in  singers  I  have  limited 
the  operation  to  those  in  whom  the  tonsillar  dis- 


SIX   MEDICAL    QUESTIONS  167 

ease  itself  seemed  about  to  destroy  the  voice,  so 
that  I  believe  that  vocalists  form  no  exception  to 
the  rule,  that  wherever  the  tonsillectomy  is  really 
indicated,  enhanced  general  vigor  and  vocal 
sturdiness  may  be  expected  to  result  from  the 
operation." 

George  B.  Wood:  "Personally,  no,  except  to 
clear  the  voice." 

George  B.  Rice:  "Yes." 

J.  E.  Newcomh:  "No." 

Charles  H.  Knight:  "Often  very  marked.  In- 
crease in  volume  and  metallic  quality,  the  latter 
diminishing  as  the  palatal  muscles  adapt  them- 
selves." 

Joseph  W.  Gleitsmann:  "Consider  carefully 
removal  of  hypertrophied  (not  otherwise  dis- 
eased) tonsils  in  professional  singers.  If  re- 
moved, influence  on  voice  is  easily  and  quickly 
relieved  by  vocal  studies,  with  benefit  to  patient." 

E.  B.  Gleason:  "Generally  a  great  improve- 
ment in  the  voice  after  the  removal  of  hyper- 
trophied tonsils.  Great  impairment  of  the  sing- 
ing voice  of  a  professional  female  singer  from  a 
tonsillectomy  done  in  New  York  probably  result 
of  great  change  in  size  of  pharynx  or  possibly 
cicatrical  contractions." 

Wesley  Mills:  "None  unfavorable — often 
good  results  both  on  the  general  health  and  the 
voice,  i.e.:  when  enlarged." 

George  L.  Ross:  "No,  but  would  not  say  they 
do  not  occur,  for  of  the  many  cases  done  yearly 
(150)  I  have  rarely  seen  the  case  more  than  twice, 
oftener  only  once,  about  a  week  after  operation. 
Have  not  had  a  case  of  secondary  hemorrhage  in 


168  THE   TONSILS   AND   THE   VOICE 

twenty  years,  but  in  every  ease  I  think  of  its  pos- 
sibilities." 

J.  Maclntyre:  "The  same  remark  applies  to 
question  number  four  that  was  made  to  answer 
question  number  three." 

St.  Clair  Thomson:  "None  but  changes  for 
the  better." 

E.  M.  Holmes:  "Yes." 

E.  W.  Scripture:  "Removal  of  enlarged  ton- 
sils improves  the  timbre  of  the  voice." 

John  N.  Mackenzie:  "The  voice  is  often  im- 
proved after  tonsillotomy  and  some  of  the  great 
singers  of  the  world  have  profited  from  it.  I 
know  of  several  cases  in  which  the  singing  voice 
has  been  ruined  after  complete  enucleation.  In 
two  cases,  teachers  of  singing  operated  on  by  a 
skilful  surgeon,  the  voices  in  same  were  destroyed 
and  the  life  work  of  the  patients  was  gone.  The 
tonsils  in  connection  with  the  other  structures  of 
the  pharynx  unquestionably  have  to  do  with  the 
character — the  timbre — of  the  voice.  It  is  im- 
possible to  foretell  exactlj^  the  amount  and  char- 
acter of  the  changes  in  anatomical  relations  after 
the  so-called  'complete'  operation,  no  matter  how 
skilful  the  surgeon  may  be  or  what  new  theoreti- 
cal hues  in  surgery  along  which  he  works.  It  is 
therefore  of  urgent  importance  to  proceed  with 
great  caution  in  those  who  make  professional  use 
of  their  voices ;  if  I  were  a  great  singer  I  should 
never  consent  to  a  tonsillectomy  except  as  a  very 
last  resort." 

Massei:  "Never." 

Luc:  "The  singers  generally  stated  an  im- 
provement of  their  vocal  powers.     I  never  came 


SIX    MEDICAL    QUESTIONS  169 

across  any  who  complained  of  any  bad  conse- 
quence." 

Casteoc:  "I  have  observed  to  my  satisfaction 
the  voice  gains  in  facility  and  sonority." 

Moure:  "After  the  ablation  of  the  tonsils  a 
change  of  the  voice  is  above  all  observed  when  the 
subject  has  already  been  accustomed  to  singing, 
and  that  in  consequence,  he  has  habituated  him- 
self to  emit  the  voice  with  the  two  tonsils  situated 
between  the  pillars.  If  the  forms  of  certain 
hypertrophied  tonsils  embarrass  the  speaking 
(phonation)  there  is  no  doubt  that  there  is  then, 
after  their  removal,  a  very  appreciable  modifica- 
tion in  the  emission  of  the  speaking  voice  among 
young  persons." 

Escat:  "I  have  only  observed  a  modification  of 
the  timbre  and  the  volume  of  the  voice,  but  rather 
for  good  than  bad.  Among  professional  singers 
the  result  obliges  them  to  modify  the  vocal  emis- 
sion (to  bear  upon  the  sound)  differently;  an 
artist  may  be  obliged  to  reconstruct  somewhat  his 
vocal  education,  and  to  modify  his  pharyngeal 
gymnastics;  but  he  will  do  this  rapidly  and  his 
voice  will  rather  gain  by  the  operation." 

A.  Earth:  "Voice  improves  after  removal  of 
hypertrophic  tonsils,  but  can  also  get  worse, 
never  the  consequence  of  anatomical  conditions." 

Eugene  Hodenpyl:  "No." 

Schmiegelow:  "None,  if  the  tonsils  were  not 
hypertrophied." 

Frank  E.  Miller:  "Yes.  High  range,  more 
timbre,  better  resonance  if  by  removal  of  abnor- 
mal tonsils  sometimes  through  dry  catarrh  and 
irritating  compensatory  glandular  or  other  ele- 


170  THE    TONSILS    AND    THE    VOICE 

merits  of  mucous  membrane  or  swellings  of 
glands  extending  down  the  sides  of  the  palate." 

Van  Baggen:  "The  other  case,  where  the  ton- 
sils were  removed,  was  a  singer.  Here  also  the 
removal  of  the  swollen  tonsils  appeared  unavoid- 
able because  of  the  impossibility  to  correct  a 
nervous  contraction  of  the  pillars  of  the  fauces. 
As  a  result  of  the  removal  entire  success  followed. 
It  did  not  affect  the  timbre  of  the  voice;  an  in- 
crease of  resonance  was  observed  and  she  sang 
with  far  more  ease  and  less  fatigue." 

Von  Chiari:  "If  in  older  mammals  (or  in- 
fants) very  large  tonsils  which  have  stretched 
the  palatine  arches  very  much,  if  they  have  been 
removed  to  the  bottom  of  the  sinus  tonsillarus, 
then  these  arches  lose  their  props  (supports) ,  and 
on  account  of  relaxing  of  their  muscles  (the 
muscles  of  the  arches)  they  cannot  contract 
themselves  thoroughly  any  more.  Therefore, 
the  resonance  of  the  throat  gets  flabby  walls,  so 
that  the  strength  and  fulness  of  the  tones  suffer." 


SIX   MEDICAL    QUESTIONS  171 

LETTER  OF  ESCAT. 

Translation. 

Doctor  Escat, 
2,  Rue  Cantegril,  2, 
Toulouse. 

REPLY  OF  DR.  ESCAT,  TOULOUSE, 
TO  TONSIL  REFERENDUM. 

Answer  to  Question  1.  I  am  of  the  opinion 
that  the  faucial  tonsils  have  not  for  their  only 
function  that  of  phagocytosis  studied  by  Metch- 
nikofF,  but  also  a  physiological  and  biological 
function  due  to  an  internal  secretion,  like  all  the 
secretory  internal  glands  (thymus,  thyroid,  liver, 
etc.). 

Answer  to  Question  2.  I  am  of  the  opinion, 
in  accord  with  Allen,  that  the  tonsils  (palatine, 
pharyngeal,  lingual,  tubaire)  secrete  a  principle, 
the  nature  of  which  it  has  been  unable  as  yet  t3 
determine  but  which  should  be  useful  in  the  de- 
velopment and  to  the  growth  of  the  subject,  and 
probably  to  the  growth  of  the  skeleton.  I  have 
found  a  reason  for  this  in  the  fact  that  the  normal 
tonsils  atrophy  normally  about  the  age  of  eighteen 
to  twenty  years,  from  the  time  that  the  subject 
has  become  fully  an  adult.  This  normal  atrophy 
is  manifest  and  striking  for  the  pharyngeal, 
tubaire  and  lingual  tonsils;  it  is  more  defaced 
and  more  dissimulated  in  the  faucial  tonsils  by 
reason  of  their  globate  form ;  this  is  why,  in  spite 
of  the  atrophy,  there  always  persists  a  small  nut 
or  nucleus,  but  this  atrophied  tonsil  is  nothing 


172  THE    TOXSILS    AKD    THE    VOICE 

but  a  stump  of  a  tonsil ;  when  that  atrophied  ton- 
sil has  conserved  in  the  adult,  a  certain  " gro- 
neur"  (grandeur) ,  it  is  because  it  is  sick;  it  is  be- 
cause the  chronic  inflammation  has  counteracted 
the  physiologic  atrophic  involution. 

Answer  to  Question  3.  I  have  observed  noth- 
ing but  good  effects — amelioration  of  the  general 
condition,  exaggeration  of  the  development  in 
the  child.  I  attribute  the  good  result  as  much  to 
the  cessation  of  physiologic  troubles  resulting 
from  the  vicious  internal  tonsillary  secretion  from 
the  chronic  inflammation,  as  to  the  cessation  of 
the  mechanical  interference  brought  on  by  the 
hypertrophy — no  cachexia  tonsilliprive  has  been 
observed  because,  even  in  the  most  radical  abla- 
tion of  the  tonsils,  there  is  alwaj^s  left  a  little  ade- 
noid tissue. 

Answer  to  Question  4.  I  have  only  observed 
a  modification  of  the  timbre  and  the  volume  of 
the  voice — but  rather  for  good  than  bad.  Among 
professional  singers  the  result  obliges  them  to 
modify  the  vocal  emission  ("to  bear  upon  the 
sound")  differently:  an  artist  may  be  obliged  to 
reconstruct  somewhat  his  vocal  education,  and  to 
modify  his  pharj^ngeal  gymnastics;  but  he  will 
do  this  rapidly,  and  his  voice  will  rather  gain  by 
the  operation. 

Answer  to  Question  5.  I  am  not  a  partisan  of 
systematic  ablation;  I  am  not  a  partisan  except 
of  the  ablation  of  hypertrophied  tomils  or  those 
suffering  from  chronic  inflammations  causing  re- 
peated tonsillitis,  or  peritonsillitis,  etc.,  etc. 

I  am  of  the  opinion  that  we  need  not  seek  to 
leave   tonsillitic   tissue    (for   one    always   leaves 


SIX   MEDICAL    QUESTIONS  173 

some  in  spite  of  himself)  sufficient  that  (with 
children)  the  function  of  internal  secretion  of 
the  tonsils  continues  to  be  assured. 

But  on  the  other  part,  it  is  not  necessary,  in  my 
opinion,  to  set  one's  heart  upon  completely  ex- 
tracting all  the  tonsillar  tissue,  as  various  Ameri- 
can confreres  proposed. 

The  tonsil  is  not  an  epithelioma!  Further,  a 
radical  enucleation  is  very  difficult  with  certain 
subjects,  by  reason  of  the  almost  constant  exis- 
tence of  an  intra-v clique  portion  of  the  tonsil, 
which  it  is  necessary  to  dissect  with  the  bistoury, 
in  the  thickness  of  the  veil. 

Thus,  one  such  dissection  will  be  very  dan- 
gerous from  the  point  of  view  of  the  possible 
hemorrhage  (see  on  the  subject  of  the  intra- 
velique  portion  of  the  tonsil,  in  my  "Technique 
O.  R.  L.,"  pages  83  and  84,  second  edition,  Paris, 
Maloine  publisher,  lately  published).  Consult 
also  my  argument  on  the  report  of  Hicguet  and 
Broeckaert  to  the  Belgian  O.  R.  L.  Society, 
June  12,  1910  (in  "Presse  O.  R.  L.  Beige," 
Number  7,  1910). 


174  'IHE    TONSILS    AND    THE    VOICE 

Question  Number  Five. 

Would  you,  as  a  rule,  advise  the  removal  of 
normal  tonsils  ? 

Answers : 

Von  Chiari:  "No." 

Von  Schrotter:  "No." 

Van  Baggen:  "No." 

Schmiegelow:  "No." 

Castex:  "No." 

Beverly  Robinson:  "No." 

Charles  H.  Knight:  "No." 

Joseph  W.  Gleitsmann:  "No." 

E.  B.  Gleason:  "No." 

George  B.  Rice:  "No." 

E.  M.  Holmes:  "No." 

John  N.  Mackenzie:  "No." 

Eugene  Hodenpyl:  "No." 

William  G.  MacCallum:  "No." 

A.  Coolidge,  Jr.:  "No." 

G.  Hudson-Makuen :  "No." 

William  E.  Casselherry :    "No." 

Edwin  Pynchon:  "The  tonsil  which  might  ap- 
pear 'normal'  to  one,  might  appear  abnormal  in 
some  way  to  another  with  a  greater  experience  in 
the  study  of  the  tonsil  question.  Generally  we 
do  not  advise  operation  if  there  is  no  trouble  sub- 
jective or  objective.  In  fact,  such  patients  do 
not  call  for  treatment.  Many  years  ago  Bos- 
worth  said,  'The  less  tonsil  the  nearer  normal,' 
and  my  experience  causes  me  to  agree  with  him. 
The  fact  that  a  tonsil  has  never  become  inflamed 
is  no  proof  that  it  is  not  causing  or  may  not  cause 


SIX   MEDICAL    QUESTIONS  175 

trouble.  I  frequently  remove  tonsils  which  have 
been  passed  upon  by  other  specialists  as  being 
'normal'  because  I  saw  a  relationship  which  they 
did  not  see  between  the  tonsils  and  other  parts, 
as  the  nose,  the  ears,  the  pharynx,  the  larynx,  the 
pulmonary  and  gastro-intestinal  tracts,  and  the 
results  we  think  as  particularly,  and  differing  in 
different  cases,  deafness,  tinnitus,  hoarseness  (re- 
current) catarrh,  bronchitis,  cough  and  indiges- 
tion, and  therefore  more  or  less  impairment  of 
the  general  health  in  one  way  or  another." 

J.  Maclntyre:  "Question  five  is  rather  a  puz- 
zle to  me  because  it  is  hard  to  say  under  what 
circumstances  one  may  be  called  to  remove 
normal  faucial  tonsils." 

St.  Clair  Thomson:  "It  is  impossible  to  define 
what  is  a  'normal  tonsil.'  I  should  never  remove 
a  tonsil  at  any  age,  unless  convinced  that  there 
are  disorders  of  health  or  hindrances  to  develop- 
ment which  are  directly  attributable  to  it." 

Frank  E.  Miller:  "Never,  if  as  described  in 
question  number  one." 

H.  Holbrook  Curtis:  "Not  unless  they  gave 
trouble." 

Wesley  Mills:  "No.  Only  in  exceptional 
cases  if  at  all." 

George  L.  Ross:  "No.  Have  always  avoided 
doing  so." 

J.  E.  Newcomb:  "If  not  impeding  function 
by  their  size  in  adults  and  patient  is  not  subject 
to  sore  throat,  do  not  consider  removal  necessary. 
Would  remove  all  enlargements  in  patients,  say 
below  sixteen  years." 

George  B.  Wood:    "I  certainly  would  not  ad- 


176  THE   TONSILS   AND   THE   VOICE 

vise  the  removal  of  tonsils  unless  there  is  some  rea- 
son for  doing  so." 

Massei:  "No — I  advise  removal  only  when 
(although  not  much  enlarged)  they  are  the  cause 
of  frequent  sore  throat  or  when  with  the  pharyn- 
geal tonsil  they  are  concurrent  to  insufficient 
breathing." 

BartJi:  "I  do  not  remove  normal  or  slightly 
hypertrophic  tonsils  (which  do  not  cause  patho- 
logical disturbances).  If  one  wanted  to  do  that 
one  would  have  to  perform  in  any  normal  man  a 
number  of  prophylactic  operations." 

Lermoyez:  "I  consider  that  the  normal  tonsils 
are  organs  that  must  he  respected.  One  should 
never  remove  the  human  organs;  not  more  a  nor- 
mal tonsil  than  a  healthy  tooth  or  a  healthy  eye!" 

LiUC:  "No.  Unless  patients  are  subject  to 
frequent  pharyngitis,  and  we  may  hope  that  the 
suppression  of  their  tonsils  will  make  the  attacks 
less  painful." 

Moure:  "I  believe  that  in  a  general  way,  one 
should  not  remove  the  tonsils  when  they  are  not 
of  excessive  size,  or  are  not  inflamed ;  in  a  word, 
that  they  are  not  the  'point  of  departure'  of  local 
infection  frequent  or  distant  (caseous  suppura- 
tive tonsillitis).  They  are  organs  as  useful  as 
the  ganglions  when  these  latter  are  not  degen- 
erated." 

JLubet-Barhon:  "I  think  there  is  never  an  in- 
dication to  remove  a  normal  organ,  and  for  my- 
self, I  never  remove  tonsils  responding  to  the 
type  you  call  normal,  like  volume  and  like  condi- 
tion of  the  gland ;  without  chronic  inflammation, 
without  crypts,  without  adherence  to  the  pillars, 
and  elsewhere.    How  will  you  examine  the  tonsils 


SIX    MEDICAL    QUESTIONS  177 

if  the  patient  does  not  complain  of  something  in 
regard  to  them,  and  then  why  remove  them  or 
touch  them  any  more  than  the  'corner'  of  the  nose 
or  the  uvula.  I  add  that  there  are  very  few  nor- 
mal tonsils,  because  of  the  multitude  of  inflam- 
mations of  which  that  organ  is  the  seat  from  years 
of  infanc}^  and  results  of  these  inflammations — 
crypts,  adhesions,  hypertrophies." 

Esc  at:  "I  am  not  a  partisan  of  systematic 
ablation ;  I  am  not  a  partisan  except  of  the  abla- 
tion of  hypertrophied  tonsils  or  those  suffering 
from  chronic  inflammation  causing  repeated  ton- 
sillitis, peritonsillitis,  etc.,  etc.  I  am  of  the 
opinion  that  we  need  not  seek  to  leave  tonsillitic 
tissue  (for  one  always  leaves  some  in  spite  of  him- 
self) sufficient  that  (with  children)  the  function 
of  internal  secretion  of  the  tonsils  continues  to  be 
assured.  But  on  the  other  hand  it  is  not  neces- 
sary in  my  opinion,  to  set  one's  heart  upon  com- 
pletely extracting  all  the  tonsillar  tissue  as  vari- 
ous American  confreres  proposed.  The  tonsil  is 
not  an  epithelioma!  Further,  a  radical  enuclea- 
tion is  very  difficult  with  certain  subjects,  by  rea- 
son of  the  almost  constant  existence  of  an  intra- 
velique  portion  of  the  tonsil,  which  it  is  necessary 
to  dissect  with  the  bistouiy,  in  the  thickness  of 
the  veil.  Thus,  one  such  dissection  will  be  very 
dangerous  from  the  point  of  view  of  possible 
hemorrhage  (see  on  the  subject  of  the  intra- 
velique  portion  of  the  tonsil,  in  my  'Technique, 
O.  R.  L.',  pages  83  and  84,  second  edition,  Paris, 
Maloine,  publisher.  Consult  also  my  argument 
on  the  report  of  Hicguet  and  Broeckaert  to  the 
Belgian  O.  R.  L.  Society^  June  12,  1910,  in 
'Presse  O,  R.  L.  Beige/  Number  7,  1910.)" 

13 


178  THE    TONSILS    AND    THE    VOICE 

Question  Number  Six. 

Remarks  ? 

Answers : 

Charles  H.  Knight:  "I  hope  you  may  be  able 
to  throw  some  light  on  the  ever  new,  old  question 
of  function.  I  anticipate  you  will  find  a  fair 
degree  of  agreement  on  other  points.  Wish  you 
success  in  your  quest." 

E.  M.  Holmes:  "I  do  not  wish  to  be  under- 
stood as  opposed  to  removing  badly  diseased  ton- 
sils, for  I  believe  they  may  be  the  cause  of  much 
trouble." 

George  B.  Rice:  "After  removal  of  the 
diseased  faucial  tonsil  the  relations  of  the  reso- 
nant cavities  is  changed;  therefore  the  voice  of  r 
trained  singer  does  not  at  once  respond  in  the 
same  manner  as  previously.  This  difficulty  in 
tone  production  is  in  my  experience  soon  over- 
come by  training  and  readjustment  of  method, 
conforming  to  the  new  conditions.  After  this 
has  been  accomplished  the  voice  is  I  believe  im- 
proved m  quality,  in  carrying  power,  and  in  ease 
of  use." 

E.  B.  Gleason:  "The  answers  above  refer  to 
tonsillectomies  properly  done ;  and  not  to  cases  in 
which  portions  of  the  anterior  and  posterior  pillars 
or  other  muscular  portions  of  the  pharynx  were 
inadvertently  removed  with  the  tonsil,  nor  to  ton- 
sillotomies." 

Wesley  Mills:    "I  think    somewhat  enlarged 

tonsils  may  have  for  a  speaker  or  singer,  i.e.: 

cause  him  the  expenditure  of  greater  energy  to  do 

his  work  well,  even  when  they  do  not  embarrass 

V 


SIX    MEDICAL    QUESTIONS  I79 

as  greatly  enlarged  tonsils  do.  In  doubtful  cases, 
I  would  remove  them,  especially  in  singers." 

St.  Clair  Thomson:  "I  am  afraid  the  enclosed 
answers  to  your  inquiries  are  not  very  satisfac- 
tory.   I  have  few  facts  to  offer  you." 

Frank  E.  Miller:  "The  usual  cause  of  the 
singer's  node  is  tonsillitis,  which  causes  a  weaken- 
ing of  muscular  action  over  the  side  affected,  then 
a  sense  of  no  power,  then  a  relaxation,  of  cord  on 
side  affected,  then  bulging  of  the  cord,  akinesis, 
then  node  with  hyperplasia,  etc.  A  clean  enuclea- 
tion of  tonsil  in  such  a  case  cures  nodule  and  its 
consequences  in  reversion.  But  never  remove 
capsule  in  a  singer." 

"Since  your  visit  and  report  of  several  cases 
of  death  from  hemorrhage  from  ablated  tonsils, 
I  have  developed  a  system  of  aeroelectrotomy  for 
diseased  tonsils,  by  means  of  suction  and  wash- 
ings. Am  very  sorry  I  cannot  go  further  into 
the  matter  for  you  just  now.  Be  sure,  however, 
that  I  have  not  forgotten  your  skill,  care  and 
kindness,  and  wish  to  praise  and  thank  you  for 
your  great  effort  in  behalf  of  tonsillar  hygiene." 

Massei:  "I  have  operated  by  tonsillotomy  in 
2881  cases ;  I  have  not  taken  note  of  cases  in  which 
I  removed  the  faucial  tonsils  with  punch  and  in 
several  sittings.  The  modest  answers  I  have 
given  are  in  relaton  with  the  experience  of  these 
cases." 

Schmiegelow:  "I  have  never  had  serious  at- 
tacks of  bleeding  after  operation." 

Luc:  "I  have  adopted  the  practice  of  remov- 
ing the  tonsils  ordinarily  with  the  cold  snare, 
after  liberating  them  by  means  of  curved  scissors 


180  THE   TONSILS   AND   THE   VOICE 

and  drawing  them  well  out  of  their  cavity  by- 
means  of  a  special  forceps  passed  through  the 
loop."  - 

Von  Chiari:  "You  will  find  a  new  detailed 
summary  of  my  remarks  in  the  book  called  ^Die 
Kranhheiten  des  Rachens  von  O.  Chiari,  Leipzig 
und  Wien/  " 

Van  Bag  gen:  "As  I  am  exclusively  a  special- 
ist— expert  for  voice  and  speech  afflictions,  I 
considered  the  questions  but  from  the  phonetic 
point  of  view." 


The  vowel  siren  and  buccal  resonators. — Marat 


CHAPTER  IX 
THE  SCIENCE  OF  THE  VOCAL  ART. 

The  science  of  voice  mechanism,  and  the  mas-  [ 
tery  of  voice  production,  do  not  belong  to  the  , 
physician's  art.  Medical  science  reaches  its  1 
limits  at  the  science  of  the  vocal  art. 

The  study  of  voice  mechanism  presents  many 
difficult  problems.  The  mechanism  is  marvel- 
ously  delicate,  extremely  complicated,  with  ad- 
justments and  re-adjustments  easily  deranged. 

The  finest  art  is  the  art  of  song.  It  is  the  divine 
art.  To  teach  this  art  requires  intelligence,  apti- 
tude, high  ideals,  and  specialized  education. 
Teachers  of  this  art  must  he  trained  to  teach,  and 
they  must  he  credited  with  skill  and  experience 
in  the  attainment  of  artistic  results. 

The  voice  profession  may  point  with  pride  to 
the  scientific  contributions  to  the  mechanism  of 
speech,  of  such  singing  teachers  as  Bennati, 
Garcia,  John  Howard,  and  Charles  Lunn;  and  to 
the  perpetuation  of  the  vocal  art,  by  such  masters 
as  Porpora,  Tosi,  Gahrielli,  Trivuhi,  the  Lam- 
perti's,  Mme.  Cappiani,  Mme  Mott,  Mme.  Leh-^ 
mann,  Shakespeare,  De  Reszke,  Sehastiani,  the 
Marchesis,  and  many  others. 

Marage,  Scripture  and  other  voice  mechan- 
icians of  our  day  have  made  wonderful  strides 
in  acquiring  scientific  knowledge  concerning  the 
mechanism  of  speech  and  voice,  and  have  thus 
contributed  to  the  greater  security  in  the  preser- 

181 


182  THE    TONSILS    AND    THE    VOICE 

vation  of  our  inheritance  of  the  art  of  song,  as 
handed  down  by  the  great  song  masters. 

The  purpose  of  a  vocal  method  is  to  produce 
a  perfect  co-ordination  of  all  parts  of  the  human 
voice-producing  mechanism. 

The  Italians,  like  Tosi,  Porpora,  Trivulzi,  the 
JLampertis,  and  Mme.  Cappiani,  were  teachers 
of  great  practical  experience  and  they  understood 
how  to  adapt  method  to  individual  needs.  Con- 
sciously or  unconsciousl}^  their  method  was 
physiological,  and  the  fundamental  principles  of 
the  physiology  of  voice  production  were  there. 

Salvatore  Marchesi  {''A  Vademecum")  says: 

''Manuel  Garcia,  when  tr^ang  to  investigate 
the  mechanism  of  the  vocal  organ,  aimed  ex- 
clusively at  establishing  a  physiological  sj^stem 
for  the  production  and  development  of  the  voice 
in  connection  with  the  art  of  song,  and  proposed 
putting  an  end,  if  possible,  to  the  dangerous  in- 
terference of  dabblers." 

"On  the  contrary,  the  new  scientific  path  he 
had  opened  to  the  cultivation  of  the  human  voice 
fell  a  prey  to  empiricism;  thousands  of  undesir- 
able meddlers  seized  upon  the  subject  and 
brought  about  confusion." 

"A  conscientious  laryngologist  must  indeed 
study  and  investigate  the  anatomical  structure 
and  physiological  w^orking  of  the  human  vocal 
apparatus,  but  he  should  remain  on  pathological 
ground.  Laryngologists  who  publish  books  on 
'Voice  Production'  betraj^  their  mission.  The 
publication  of  their  books  complicated  with  scienti- 
fic quotations  and  dilemmas,  and  consequently 
out  of  proportion  to  the  general  standard  of  in- 


THE    SCIENCE    OF    THE    VOCAL  ART  183 

struction,  create  unconsciously  a  number  of 
physical  disorders  and  diseases  among  singing 
people,  and  thus  contribute  to  the  dedine  of  the 
art  of  song." 

"In  view  of  the  abuse  that  modern  laryngolo- 
gists,  physiologists,  and  teachers  have"  made  of 
anatomical  engravings,  illustrating  some  scienti- 
fic parts  of  their  works,  I  wish  to  avoid  any 
theoretical  example  of  the  sort." 

"It  would  certainly  be  unjust  to  deny  that 
modern  physiological  and  acoustical  investiga- 
tion has  furnished  a  broader  basis  for  studying 
the  phenomena  of  the  human  voice.  But  the  ma- 
terial furnished  by  new  scientific  discoveries  must 
he  subjected  to  servere  criticism,  and  compared 
by  the  practical  teachers  with  such  real  facts  as 
are  positively  demonstrated  by  long  experience, 
accredited  traditions  and  approved  results" 

"We  cannot  and  must  not  throw  away  all  that 
constitutes  the  inheritance  of  the  ages,  all  that 
has  furnished  evidence  of  practical  value;  but 
must  use  the  new  ideas  to  complete  and  perfect 
the  old  ones.  The  teacher  may  utilize  all  the 
precious  discoveries  made  by  modern  science,  but 
on  condition  that  he  understands  them,  and  pro- 
vided he  knows  where,  when  and  how  they  are  to 
be  employed." 

Mme.  Lilli  Lehmann  {"'How  to  Sing,"  1909) 
says:  "Singers  should  seek  to  acquire  accurate 
knowledge  of  their  own  organs,  as  well  as  of 
their  functions,  that  they  may  not  let  themselves 
be  burnt,  cut  and  cauterized  by  unscrupulous 
physicians.  Leave  the  laryncc  and  all  connected 
with  it  alone.     I  give  warning  of  unprincipled 


184  THE    TONSILS    AND    THE    VOICE 

physicians  who  daub  around  in  the  larynx,  hum 
it,  cut  it,  and  make  everything  worse  instead  of 
better.  I  cannot  comprehend  why  singers  do  not 
unite  to  brand  such  people  publicly  and  put  an 
end  to  their  doings  once  for  all." 

Manuel  Garcia,  singing  teacher,  laid  the  foun- 
dation for  the  practice  of  scientific  laryngology. 
Without  his  invention,  the  laryngoscoj)e,  there 
would  be  no  laryngologists,  and  very  incomplete 
knowledge  of  diseases  of  the  larynx.  The  dis- 
covery of  the  laryngoscope  is  not  all,  however, 
that  the  world  owes  to  the  voice  profession. 

John  Howard's  classic  work  on  the  "Physi- 
ology of  Artistic  Singing,"  including  his  great 
eccpose  of  the  j^^iy^iology  of  artistic  breathing, 
are  contributions  of  the  highest  value  to  the 
science  of  the  vocal  art. 

And  the  scientific  observations  of  Charles 
Lunn  are  impoj'tant. 

The  elaborate  scientific  investigations  of  Scrip- 
ture and  Mar  age  have  revolutionized  scientific 
thought  regarding  the  mechanism  of  speech  and 
voice.  And  they  state  that  their  great  work  is  in 
its  incipiency. 

The  genius  of  Garcia  grows  greater!  Scrip- 
ture and  Marage  have  proved  the  trutli  of  Gar- 
cia s  SECOND  great  achievement,  that  of  his  dis- 
covery of  the  PUFE  ACTION  of  the  vocal  cords. 

But  his  second  observation  was  fifty  years 
ahead  of  his  time;  so  far  ahead  that  no  one  under- 
stood or  accepted  it.  This  second  great  discov- 
ery has  waited  over  fifty  years  for  Scripture, 
Marage  and  others  to  prove  its  truth,  the  truth 


THE    SCIENCE    OF   THE    VOCAL  ART  185 

that  Garcia  persistently  taught  for  over  fifty 
years,  as  follows: 

"What  is  sound?" 

"Answer:  "The  sensation  made  in  the  ear  by 
vibrating"  air." 

"How  does  the  glottis  produce  sounds?" 

"Answer:  The  two  lips  of  the  glottis,  which 
are  separated  in  the  act  of  breathing,  meet  when 
preparing  to  produce  a  sound,  and  close  the  pas- 
sage with  the  degree  of  energy  demanded  by  the 
nature  of  the  sound  and  the  power  with  which  it 
is  to  be  emitted.  Then,  being  pushed  upwards 
by  the  air,  they  give  way  and  allow  a  portion  of 
air  to  escape,  but  immediately  return  to  their 
original  contact,  and  recommence  the  action. 
These  intermittent  emissions  or  explosions  of  air, 
when  regular  and  rapid  enough,  form  a  sound." 

"Can  you  name  any  action  which  is  an  illus- 
tration of  this?" 

"Answer:  The  action  of  the  lips  of  a  horn 
player." 

"Are  the  sounds  obtained  always  of  the  same 
character?" 

"Answer:  No.  They  may  be  bright  and 
ringing'  or  veiled." 

"How  do  you  obtain  these  bright  and  veiled 
sounds?" 

"Answer:  If,  after  every  explosion  the  glot- 
tis closes  Completely,  each  impinges  sharply  on 
the  tympanic  membrane,  and  the  sound  heard  is 
bright  and  ringing.  But  if  the  glottis  is  imper- 
fectly closed,  and  a  slight  escape  of  air  unites  the 
explosions,  the  impressions  upon  the  tympanum 
are.  blunted,  the  sound  being  then  veiled."  : 


186  THE    TONSILS    AND   THE    VOICE 

"Has  this  observation  any  importance?" 

"Answer:  Coupled  with  the  theory  of  timbres 
and  that  of  the  breath,  it  puts  the  singer  in  posses- 
sion of  all  the  'tints'  of  the  voice,  and  indeed  initi- 
ates him  into  all  the  secrets  of  voice  production." 

"What  produces  pitch?" 

"Answer:  The  number  of  explosions  that 
occur  in  a  given  time." 

"What  causes  intensity  of  sound?" 

"Answer:  Intensity  of  sound  is  not  due  to  the 
amplitude  of  movement  of  the  glottic  lips,  but  to 
the  quantity  of  air  which  makes  one  vivid  explo- 
sion. The  resistance  offered  b}^  the  lips  to  the 
pressure  of  the  lungs  determines  this  quantity. 
The  amplitude  is  therefore  a  result,  not  a  cause. 
After  each  explosion  the  glottis  must  be  re- 
closed;  for  if  the  air  found  a  constant  issue,  the 
greater  the  expenditure  of  air,  the  weaker  the 
sound  would  be." 

"How  is  volume  of  sound  obtained?" 

"Answer:  The  volume  of  sound  depends  on 
the  expansion  of  the  pharynx  and  of  the  vesti- 
bule of  the  larynx." 

Garcia  s  theory  was  fully  set  forth  in  1855  and 
published  in  the  Proceedings  of  the  Royal  So- 
ciety of  Great  Britain,  Vol.  77,  1856.  He  has 
ever  since  reiterated  his  views. 

The  vocal  cords  do  not  throw  off  vibrations  of 
sound,  like  a  snapped  cord  or  the  string  of  a 
violin,  but  it  is  well  illustrated  by  Professor 
George  M.  Sleeth,  who  states  that : 

"As  the  column  of  air  coming  from  the  lungs 
meets  the  resistance  of  the  closed  glottis,  it  is 
forced  against  the  vocal  cords,  which  by  their  re- 


THE    SCIENCE    OF    THE    VOCAL  ART  Igy 

sistant  flexibility  chop  or  clip  it  into  a  series  of 
instantaneous  and  continuous  puffs  or  explosions 
of  compressed  air,  which  shock  the  surrounding 
air,  and  the  reports  are  heard  as  continuous  tone." 

The  puff  theory  of  Garcia  has  been  accepted 
by  Hermann,  Scripture  and  Marage. 

Scripture,  in  "Researches  in  Eocperimental 
Phonetics''  says: 

"The  two  essentials  of  the  theory,  as  stated  by 
Willis  and  Hermann,  namely:  'That  the  glottis 
emits  puffs  of  greater  or  less  sharpness,  and  that 
the  vocal  tones  are  generally  inharmonic  to  the 
glottal  tone,  can  he  considered  as  definitely  estab- 
lished. The  reason  for  the  puff  character  of  the 
glottal  action  has  been  found  by  Professor  Ewald 
(Strassburg)  in  the  fact  that  the  glottal  lips  are 
masses  of  muscle  which  yield  by  compression  and 
do  not  vibrate  like  membranes.  These  facts  have 
remained  largely  unknown,  and  we  still  find  in 
the  text-books  the  totally  false  theory  that  the 
vowels  are  produced  by  membrane-like  vibrations 
in  the  larynx." 

"I  have  adopted  the  puff  theory  and  have 
taken  into  consideration  some  further  elements 
also,  namely:  friction  in  the  vocal  cavities  and 
associative  formation  of  the  vowel  at  the  glottis." 

"According  to  the  puff  theory,  the  glottis 
emits  a  series  of  more  or  less  sharp  puffs;  each 
puff,  striking  a  vocal  cavity,  produces  a  vibration 
whose  period  is  that  of  the  cavity;  a  single  wave 
group  shows  the  sum  of  these  vibrations  from  all 
the  cavities.  The  glottal  lip  bears  no  resem- 
blance to  a  membrane  or  string.  These  puffs  act 
on  the  vocal  cavity,  that  is,  on  a  complicated  sys- 


188  THE    TONSILS    AND    THE    VOICE 

tern  of  cavities  (trachea,  larynx,  pharynx,  mouth, 
nose)   with  variable  shapes,  sizes  and  openings." 

"The  entire  intellectual  and  emotional  impres- 
sion conveyed  by  the  voice  from  the  speaker  to 
the  hearer  is  contained  in  the  speech  vibration  and 
registered  in  the  speech  curve.  Hardly  any 
problem  of  greater  interest  could  be  proposed 
than  that  of  discovering  the  manner  of  getting 
from  a  voice  curve  the  data  concerning  the  action 
of  the  vocal  organs  in  such  an  exact  and  minute 
form  that  conclusions  can  be  drawn  concerning 
the  variations  in  the  voice  as  depending  on  every 
emotion,  on  every  condition  of  health,  on  every 
step  in  voice  culture,  on  every  difference  in  vow- 
els and  consonants,  on  each  change  in  dialect,  etc. 
The  problem,  however,  is  too  vast  for  solution  in 
a  short  time." 

"The  experimental  analysis  of  the  action  of  the 
vocal  organs  in  speech  is  already  well  developed 
and  forms  almost  a  science  by  itself.  A  first  at- 
tempt at  something  different,  namely :  an  experi- 
mental analysis  of  the  sounds  heard  by  the  ear, 
will  here  be  described." 

"An  element  of  speech  may  be  'physically'  de- 
fined hy  the  properties  of  the  vibrations  trans- 
mitted through  the  air.  It  may  be  'physiologi- 
cally' defined  by  a  description  of  the  action  of 
the  vocal  organs  producing  it,  or  of  the  ear  re- 
ceiving it.  Or,  finally,  it  may  be  'psychologi- 
cally' defined  by  a  description  of  the  hearer's  or 
speaker's  perception  of  the  sound  as  heard  or 
spoken." 

"A  vowel  analysis  maj^  be  physical,  physiologi- 
cal or  psychological." 


THE    SCIENCE    OF    THE    VOCAL  ART  Igg 

"Krause  reports  the  case  of  a  tenor  whose  glot- 
tal lips  looked  like  two  ridges  of  red  flesh  and 
whose  tones  appeared  nevertheless  unusually 
sweet  and  soft.  Imhofer  observed  a  singer  with 
hypertrophy  of  one  of  the  ventricular  bands  so 
that  the  glottal  lip  appeared  as  only  a  small  edge 
beneath  the  heavy  mass  of  the  ventricular  band 
resting  upon  it ;  with  this  apparently  unavailable 
organ  he  is  a  successful  tenor  on  one  of  the 
largest  German  stages." 

"^Both  these  cases  can  be  understood  on  the 
pufF  theory,  according  to  which  the  glottal  lips  in 
most  cases  come  together  at  each  vibration  and 
open  only  to  emit  the  puff*  of  air." 

"According  to  the  puff  theory  of  Willis  and 
Hermann,  the  glottis  emits  a  series  of  more  or 
less  sharp  puffs ;  each  puff,  striking  a  vocal  cav- 
ity, produces  a  vibration  whose  period  is  that  of 
the  cavity ;  a  single  wave-group  shows  the  sum  of 
these  vibrations  from  all  the  cavities ;  the  periods 
of  these  vibrations  may  stand  in  any  relation  to 
the  interval  at  which  the  puffs  come;  that  is,  to 
the  fundamental." 

"This  theory  is  certainly  correct  in  asserting 
that  the  glottal  tone  (the  fundamental)  consists 
of  a  series  of  more  or  less  sharp  puffs.  The 
puff  action  of  the  vocal  lips  has,  moreover,  been 
directly  observed  for  male  bass  voices  by  the 
laryngostroboscope. ' ' 

"The  pitch  of  a  cavity  tone  is  to  a  great  extent 
independent  of  the  interval  of  the  puffs.  A 
sharp  puff  acting  on  a  cavity  will  arouse  a  vibra- 
tion whose  period  is  that  natural  to  the  cavity," 

"Each  glottal  lip  consists  mainly  of  a  mass  of 


190  THE    TONSILS    AND    THE    VOICE 

muscle  supported  at  the  ends  and  along  the  lat- 
eral side.  It  bears  no  resemblance  to  a  mem- 
brane or  string.  The  two  lips  come  together  at 
their  front  ends,  but  diverge  at  the  rear.  The 
rear  ends  are  attached  to  the  arytenoid  cartilages. 
When  the  ends  are  brought  together  by  rotation 
of  these  cartilages,  the  medial  surfaces  touch.  At 
the  same  time  they  are  stretched  by  the  action  of 
the  cricothyroid  muscles,  which  pull  apart  the 
points  of  support  at  the  ends." 

"In  this  way  the  two  masses  of  muscle  close 
the  air  passage.  To  produce  a  vowel  such  a  rela- 
tion of  air-pressure  and  glottal  tension  is  ar- 
ranged that  the  air  from  the  trachea  bursts  the 
muscles  apart  for  a  moment,  after  which  they 
close  again ;  the  release  of  the  puff  of  air  reduces 
the  pressure  in  the  trachea  and  they  remain  closed 
until  the  pressure  is  again  sufficient  to  burst  them 
apart.  With  appropriate  adjustments  of  the 
laryngeal  muscles  and  air  pressure,  this  is  kept 
up  indefinitely,  and  a  series  of  puffs  from  the 
larynx  is  produced.  The  glottal  lips  open  partly 
by  yielding  sidewise — that  is,  they  are  compressed 
— and  partly  by  being  shoved  upward  and  out- 
ward. The  form  of  puff — sharp  or  smooth — is 
determined  by  the  way  in  which  the  glottal  lips 
yield;  the  mode  of  yielding  depends  on  the  way 
in  which  the  separate  fibers  of  the  muscles  are 
contracted.  When  contracted  along  the  medial 
edge,  the  action  may  approach  that  of  a  stretched 
string  loaded  with  a  soft  mass  along  its  middle 
portion  or  along  its  entire  length.  When  con- 
tracted more  laterally,  the  action  may  approach 
that  of  a  soft  mass  flapping  in  a  current  of  air, 


THE    SCIENCE    OF    THE    VOCAL  ART  19 1 

or  of  two  soft  cushions  striking  together.  These 
two  forms  of  contraction  correspond  to  separate 
action  of  the  M.  vocahs  and  the  M.  thyreoaryte- 
noides  (externus).  When  the  slant  fibers  which 
insert  along  the  medial  edge  of  the  glottal  lips 
are  contracted,  there  will  be  nodal  points  similar 
to  those  of  stretched  strings." 

"These  diiFerences  produce  differences  in  the 
forms  of  the  puffs.  We  can  thus  explain  the 
forms  of  puffs  in  the  different  types  of  vowels 
by  differences  in  the  action  of  the  muscles  of  the 
glottal  lips." 

"Physically  stated,  a  vowel  consists  of  a  series 
of  explosive  puffs  of  air  from  the  glottis  acting 
on  a  complicated  cavity  with  considerable  fric- 
tion. The  puffs  of  air  may  be  very  brief  and 
may  be  separated  by  comparatively  long  inter- 
vals of  rest,  or  they  may  be  of  smoother  form, 
even  resembling  a  tuning-fork  vibration.  The 
period  from  one  puff  to  the  next  determines  the 
pitch  of  the  voice;  the  form  of  the  puff  deter- 
mines the  musical  timbre." 

"These  puffs  act  on  the  vocal  cavity;  that  is, 
on  a  complicated  system  of  cavities  (trachea, 
larynx,  pharynx,  mouth,  nose)  with  variable 
shapes,  sizes  and  openings.  The  effect  of  the 
puff  on  each  element  of  the  vocal  cavity  is  double ; 
first,  to  arouse  in  it  a  vibration  with  a  period  de- 
pending on  the  cavity;  second,  to  force  on  it  a 
vibration  of  the  same  period  as  that  of  the  set  of 
puffs.  The  prevalence  of  one  of  the  factors  over 
the  other  depends  on  the  form  of  the  puff,  the 
walls  of  the  cavities,  etc.  Some  vowels  include 
the  puff  element  as  an  important  component, 


192  THE    TONSILS    AND    THE    VOICE 

others  consist  almost  entirely  of  the  cavity  vibra- 
tions." 

"The  vowel  curve,  according  to  this  theory, 
contains  the  record  of  the  glottal  puffs  and  of  the 
set  of  cavity  tones  aroused  by  it.  In  a  single 
wave  there  is  not  only  a  record  of  one  glottal 
puff  and  of  the  cavity  tones  for  one  vibration, 
but  also  of  what  is  left  over  from  the  fading 
vibrations  of  the  preceding  wave." 

"In  speech  the  pitch  of  the  glottal  tone 
changes  continual^.  As  the  pitch  of  the  tone 
from  the  glottis  rises,  the  group  of  cavity  vibra- 
tions come  closer  and  finally  overlap.  This  pro- 
duces veiy  complicated  forms,  but  when  the  pe- 
riod of  the  puff  becomes  an  even  multiple  of  that 
of  the  cavity,  the  waves  sum  up  in  like  phases 
and  strong,  smooth  vibrations  result." 

"For  the  ear  the  succession  of  puffs  produces 
the  tone  of  the  voice;  that  is,  the  pitch  of  the 
sound  heard  depends  on  the  interval  at  which  the 
puff  comes.  The  form  of  the  wave  impresses 
the  ear  with  the  effect  of  timbre,  that  is,  with  its 
character  as  more  or  less  musical  and  also  with  its 
vowel  character." 

"A  frietional  analysis  is  required  by  the  only 
theorj^  of  vocal  action  which  we  can  accept.  The 
simple  harmonic  analysis  can  lead  only  to  false 
conclusions." 

"In  speech  vibrations  the  friction  cannot  be 
neglected.  For  small  movements,  the  friction 
may  be  considered  as  proportional  to  the  velocity 
and  opposed  to  the  movement." 

"It  is  evident  that  the  complete  analysis  of  a 
Vowel  wave  is  not  a  light  undertaking.     We  can- 


No.  1 


No.  2 


Photographs  of  the  voice  in  singring  the  same  exercise.— AfaraffC. 
1.     French  method.  2.     Italian  method. 


Both  numbers  represent  the  same  exercise  well  sung,  and  indicate  that 
in  th/s  case,  the  Italian  method  has  produced  the  more  agreeable  im- 
pression on  the  ear. 


THE    SCIENCE    OF    THE    VOCAL  ART  193 

not  escape  from  it,  if  the  work  is  to  have  scientific 
value.  A  single  trustworthy  analysis  is  an 
achievement.  When  many  such  analyses  have 
been  accumulated,  we  can  hope  for  correct  views 
of  the  physical  and  physiological  nature  of  the 
vowels  and  reliable  data  concerning  the  vowels 
of  a  language;  we  can  ultimately  expect  in  this 
way  to  have  accurate  knowledge  with  which  to 
replace  the  vagueness  and  error  prevalent  at  the 
present  day." 

Mar  age.  (''Etude  des  Vibrations  de  la 
Voice")    Vibrations  of  the  Voice. 

"As  to  the  special  timbre  of  each  voice,  it  de- 
pends probably  upon  the  size  of  the  opening  of 
the  glottis,  on  the  tension  of  the  vocal  cords,  on 
their  size,  on  the  volume  of  the  ventricles  of  Mor- 
gagni,  on  the  position  of  the  teeth,  quantities  es- 
sentially variable  not  only  with  each  individual, 
but  also  with  the  actual  state  of  the  mucosae." 

"The  vowels  are  due  to  an  intermittent  aero- 
laryngeal  vibration,  reinforced  by  the  buccal 
cavity  and  producing  ou,  o,  a,  e,  i,  when  these  are 
put  in  unison  with  the  sum  of  the  vibrations, 
transformed  by  them,  and  giving  birth  to  other 
vowels  when  that  unison  no  longer  exists:  the 
number  of  the  intermittances  gives  the  funda- 
mental note  on  which  the  vowel  is  emitted." 

"If  the  buccal  cavity  alone  operates ^  we  have 
the  whispered  vowel." 

"If  the  laryncc  operates  alone^  we  have  the 
sung  vowel." 

"If  both  operate  at  the  same  time  we  have  the 
spoken  vowel" 

14 


X94  J^^HE    TONSILS    AND    THE    VOICE 

Mar  age.  {''Les  Voyelles  Laryngiennes" 
1909.)      The  laryngian  vowels. 

"The  vowel  is  an  intermittent  aero-laryngian 
vibration.  The  buccal  cavity  only  serves  to  re- 
inforce or  to  transform  it  (Report  made  Novem- 
ber, 1908),  and  as  there  are  not  two  mouths  ex- 
actly the  same,  we  obtain  for  the  same  vowel,  as 
many  traces  as  there  are  different  singers,  if  we 
inscribe  all  the  vibrations  giving  the  special  tim- 
bre of  each  voice." 

"It  now  remains  to  determine  experimentally 
the  place  in  the  larynx  where  that  intermittent 
vibration  is  produced." 

Mar  age.  (''Differents  Traces  d'Une  Meme 
Voyelle  Chant ee.")  Different  Traces  of  the 
Same  Vowel  as  Sung. 

"The  fundamental  vowels,  ou,  o,  a,  e,  i,  are 
formed  in  the  larynx.  These  laryngeal  vowels 
are  either  reinforced  or  transformed  by  the  buc- 
cal cavity." 

"In  that  which  is  about  to  be  said,  no  account 
is  taken  of  the  accessory  harmonics  which  give 
the  special  timbre  to  each  voice." 

"Then,  to  each  laryngeal  vowel  well  emitted, 
corresponds  one  form,  and  one  only,  of  the  buc- 
cal cavity,  for  a  determined  subject.  If  that 
condition  does  not  exist,  the  vowel  is  badly  emit- 
ted; that  is  to  saj%  transformed,  and  the  charac- 
teristic curve  no  longer  exists." 

"We  can  comprehend  why  it  is  so  rare  to  en- 
counter singers  having  a  good  diction  (fine  pro- 
nunciation) ;  a  beautiful  voice  depends  solely  on 
the  larynx  and  the  ear ;  that  is  to  say,  on  anatomic 
conditions ;  a  good  diction  necessitates  a  series  of 


Molds  of  the  buccal  cavity  pronouncing  the  vowels. — Maragcm 


THE    SCIENCE    OF    THE    VOCAL  ART  195 

long  and  difficult  studies,  which  few  singers  have 
the  courage  to  make  completely." 

Marage.  ("Etude  des  Vibrations  Lar- 
yngiennes,"  November  22,  1909.)  Study  of  the 
Laryngian  Vibrations. 

"I  have  studied,  until  now,  by  the  processes  of 
biological  physics,  the  vibrations  of  speech;  ana- 
lytical and  sj^nthetical  experiments  have  led  me 
to  admit  that  the  voice  is  an  intermittent  aero- 
laryngian  vibration  reinforced  or  transformed  by 
the  supra-laryngian  resonators,  and  in  particular 
by  the  mouth ;  but  it  is  necessary  to  directly  prove 
that  the  larynx  alone  is  capable  of  producing 
these  vibrations." 

"I  have  been  able,  with  the  living  subject,  to 
completely  annul  the  role  of  the  buccal  cavity,  by 
filling  it  with  stents,  the  substance  which  dentists 
use  for  taking  impressions;  an  unbending  cylin- 
drical tube  traverses  the  stents  and  conducts  the 
vibrations  to  the  exterior ;  there  is  then  no  longer 
any  buccal  vocable,  since  there  is  no  longer  any 
resonator;  however,  the  larynx  produces  per- 
fectly the  five  vowels,  ou,  o,  a,  e,  i ;  these  are  then 
laryngeal  vowels;  furthermore,  their  traces  are 
characteristic." 

"It  is  necessary  to  push  the  experiment 
further,  completely  isolate  a  larynx  and  cause  it 
to  render  sounds  analogous  to  those  which  it  pro- 
duces during  life.  This  is  why  I  have  again 
taken  up  these  experiments  on  the  larynx  of 
dogs." 

"Technic. — Three  hours  after  having  been  in- 
jected with  morphine,  the  animal  is  put  to  sleep 
with  chloroform  and  during  the  sleep,  the  larynx 


196  THE    TONSILS    AND    THE    VOICE 

is  removed  with  the  hyoid  bone  and  the  five  or  six 
rings  of  the  trachea ;  a  tube  of  caoutchouc  of  the 
same  diameter  as  the  trachea  is  fitted  to  it  by  a 
tube  of  thin  glass,  in  such  a  manner  as  to  permit 
a  current  of  air  to  pass,  the  pressure  of  which  is 
measured  with  metalhc  manometer  extra  sensitive, 
graduated  in  miUimeters  of  water.  This  air  can 
be  taken  from  a  reservoir  of  about  37  degrees." 

"The  IsLTyngeal  muscles  are  submitted  to  an  in- 
duction current  produced  by  a  small  'hohine  a 
chariof;  the  primary  current  is  produced  b}^  one 
accumulator  only.  The  larynx  is  photographed 
with  magnesium  on  plates  sensitive  to  red,  and 
the  vibrations  are  inscribed  on  a  phonograph." 

"Results. —  (1)  If  the  larynx  has  been  re- 
moved during  the  chloroform  sleep,  the  muscles 
can  contract  during  three  to  ten  minutes  at  the 
most." 

"  (2)  To  produce  the  vibrations,  the  current  of 
air  must  have  a  varying  pressure,  as  in  man  dur- 
ing phonation,  between  150  and  200  millimeters 
of  water." 

"  ( 3 )  If  the  excitor  is  placed  on  a  level  with  the 
crico-arytenoid  posterior  muscles,  the  glottis 
opens  wide,  the  vocal  cords  separate  to  the  maxi- 
mum and  there  is  no  sound." 

"  (4)  If  the  excitor  is  placed  at  the  level  of  the 
ary-arytenoids,  the  arytenoids  approach  each 
other  and  we  obtain  a  fine  low  note  recalling  to 
such  an  extent  as  to  be  easily  mistaken  for  the 
barking  of  a  dog  on  a  continuous  note  of  the  oc- 
tave 1." 

"  (5)  If  the  excitor  is  disposed  in  such  a  man- 
ner as  not  only  to  contract  the  ary-arytenoids,  but 


THE    SCIENCE    OF    THE    VOCAL  ART  197 

also  the  thyro-arytenoids  (vocal  cords),  we  ob- 
tain a  note  very  pure  and  very  high,  belonging 
to  octave  5;  it  is  a  kind  of  whistle  on  u,  corre- 
sponding to  the  howling  of  dogs,  who  at  night, 
bay  the  moon." 

"This  note,  very  high  and  sharp,  has  been  ob- 
tained from  a  dog  of  medium  height;  in  the 
photograph  we  see  that  the  arytenoids  have 
almost  ridden  one  over  the  other,  the  glottis  has 
become  very  slender  and  very  short." 

"(6)  The  height  of  the  note  does  not  seem 
to  depend  either  on  the  current,  nor  on  the 
pressure  of  the  air,  but  solely  from  the  position  of 
the  excitor;  that  is  to  say,  of  the  muscles  which 
contract." 

"  (7)  In  any  case,  the  laws  of  the  vibrations  of 
cords  have  not  appeared  to  me  to  be  applicable 
to  vibrations  of  the  vocal  cords ;  these  latter  have 
no  sound  by  themselves;  it  is  the  air  which 
vibrates." 

"Conclusions. —  ( 1 )  In  taking  the  precautions 
which  I  have  indicated,  these  experiments  are 
very  easy  to  repeat." 

"  ( 2 )  The  photographs  show  that,  at  each  note, 
the  entire  larynx,  including  the  epiglottis,  changes 
in  form." 

"(3)  To  each  note  corresponds  a  special  form 
of  the  entire  organ,  and  the  larynx  is  an  instru- 
ment of  music  which  changes  its  form  at  each 
note." 

"(4)  If  to  this  is  added  the  influence  of  the 
supra-laryngial  resonators,  we  comprehend  the 
diversity  of  the  tracings  which  are  obtained  for 
the  same  vowel.    If  the  apparatus  inscribed  every- 


198  THE    TONSILS    AND    THE    VOICE 

thing,  it  is  safe  to  say  that  there  are  no  two 
tracings  alike,  for  there  are  no  two  sounds  ab- 
solutely the  same." 

"(5)  The  vocal  cords  do  not  act  at  all  like 
membranous  reeds  in  caoutchouc,  and  there  is  not 
any  resemblance  between  the  sounds  rendered  by 
reeds  in  caoutchouc  and  the  sounds  rendered  by 
the  isolated  larynx." 

"(6)  Do  these  vibrations  produce  themselves 
at  the  level  of  the  glottis;  that  is  to  say,  at  the 
moment  when  the  air  passes  between  the  vocal 
cords,  or  have  the  ventricles  of  Morgagni,  as 
Savart  supposes,  a  preponderating  influence  ?  It 
is  a  question  which,  for  the  moment,  it  is  im- 
possible to  determine." 

"  (7)  We  comprehend  that  the  voice  may  sud- 
denly disappear  without  apparent  lesions  of  the 
vocal  cords,  for  all  the  adductor  muscles  and  all 
the  articulations  of  the  laryngeal  cartilages  are 
subject  to  rheumatic  lesions,  which  may  occur  in 
a  very  short  time." 

John  Howard  C"^ Physiology  of  Artistic  Sing- 
ing." 1886)  says:  "The  vocal  cords  are,  in  the 
main,  two  shelves  of  flesh  more  tender  than  the 
flesh  of  the  softest  fingers,  and  more  easily 
squeezed  or  pressed  into  different  shapes.  They 
are  about  as  soft  as  the  flesh  on  the  inside  of  the 
cheeks." 

"The  usual  pictures  of  the  vocal  organs  are 
misleading." 

"The  false  cords  are  also  small  fleshy  masses, 
similar  to  the  vocal  shelves  (true  cords)  below  in 
material,    and   quite   as   capable   of  producing 


THE    SCIENCE    OF    THE    VOCAL  ART  199 

sounds  of  definite  pitch  as  the  fleshy  parts  of  the 
fingers  or  the  true  vocal  shelves  (true  cords)." 

Liskovius  in  1814,  in  his  experiments  upon  the 
dead  larynx  did  make  them  produce  a  succession 
of  musical  sounds  by  bringing  them  together  with 
pincers  and  blowing  between  them. 

Alexander  Graharn  Bell  {''Mechanism  of 
Speech,  Third  Edition,  1908")  says: 

"Every  change  in  the  shape  of  the  passage 
waj^  through  which  the  voice  is  passed,  occasions 
a  corresponding  change  in  the  quality  of  the 
voice." 

"The  ventricles  also,  the  spaces  between  the 
true  and  false  vocal  cords  on  either  side,  should, 
theoretically,  exert  an  influence  on  the  quality  of 
the  voice,  for  they  constitute  two  small  reson- 
ance chambers,  situated  close  to  the  source  of 
sound." 

John  Howard  {''Physiology  of  Artistic  Sing- 
ing'') says: 

"The  truth  is,  that  very  powerful  contractions 
must  be  made  to  support  even  a  soft  and  mild 
tone  of  artistic  quality." 

"Likewise,  the  true  delivery,  though  it  excites 
no  sensation  of  palatal  effort,  so  flrmly  tenses  the 
palate  that  it  must  be  pushed  very  strongly  before 
it  will  give  way.  These  and  many  other  tests 
establish  the  indubitable  fact  that  all  powerful 
tones  are  the  result  of  powerful  muscular  effort." 

"The  surest  test  of  feeble  throat  action  is 
pressure  of  the  finger  against  the  sternohyoid 
muscle  just  above  the  breast  bone.  If  the  finger 
detects  no  apparent  swelling  (virtual  straighten- 


200  THE    TONSILS    AND    THE    VOICE 

ing)  very  little  extrinsic  effort,  either  right  or 
wrong,  is  being  made." 

"The  writer  has  yet  to  learn  a  single  fact  valu- 
able in  artistic  singing  which  has  been  revealed  by 
the  laryngoscope." 

"To  the  anatomist  or  physiologist,  the  sm^geon 
or  even  the  general  practitioner,  no  smallest  part 
of  the  whole  throat  can  seem  unimportant." 

"To  quote  the  words  of  Baron  Cuvier,  in  intro- 
ducing Bennati's  'Recherches  sur  le  mecanisme 
de  la  voix  humaine/  to  the  Royal  Academy  of 
Sciences^  that  not  only  the  muscles  of  the  larynx 
serve  to  modulate  the  voice,  but  also  those  of  the 
hyoid  bone,  those  of  the  tongue  and  those  of  the 
veil  of  the  palate,  without  which  one  could  not  at- 
tain the  degree  of  modulation  necessary  for  sing- 
ing." 

"That  the  upper  part  of  the  voice  channel  has 
great  influence  upon  the  nature  of  the  tone  and 
principally  upon  the  formation  of  the  mouth-tone 
is  proved." 

"Furthermore,  the  greater  size  of  the  tongue 
is  noted  when  the  voice  is  especially  full  and  re- 
sonant. The  renowned  Catalini,  Lablache  and 
Santini  furnished  examples." 

"Bennati  found  that  the  soft  palate  was  less 
decidedly  lowered  for  high  notes ;  but  the  positive 
contraction  of  the  palate-larynx  muscles  ( palato- 
laryngei)  is  shown  by  the  narrowed  forms  of  the 
palatine  arches." 

"The  inferior  constrictor,  between  the  cricoid 
cartilage  and  the  spine,  forms  the  main  boundary 
of  the  lower  end  of  the  purse-like  pharynx. 
Whate  /er  is  swallowed  must  come  into  direct  con- 


THE    SCIENCE    OF    THE    VOCAL  ART  201 

tact  with  this  muscle,  and  in  this  fact  is  found  the 
reason  why  different  habits  affect  the  voice  so 
differently  and  seriously.  Many  sing  better  after 
eating,  because  the  descending  food  and  drink 
have  cleared  away  all  thickened  mucus  or  re- 
dundant moisture.  More  commonly  the  excessive 
flow  of  the  secretions  impairs  the  tone  by  making 
the  layer  between  larynx  and  spine  too  thick  to 
check  the  backward  cricoid  movement  as  fully 
as  before,  and  too  thick,  also,  to  communicate  the 
laryngeal  vibration  to  the  spine." 

"Spiritous  liquors  inflame  all  mucous  mem- 
branes and  their  influence  upon  tone  is  unmistak- 
able.   Malt  liquors  appear  to  be  most  harmful." 

Escat.  {Maladies  of  the  Pharynx.)  Role  of 
the  Pharynx  in  Phonation  and  Articulation. 

"The  veil  of  the  palate  by  its  movements  of 
rising  and  lowering  contribute  in  a  large  part  to 
the  formation  of  certain  vowels  and  consonants." 

"  ( 1 )  The  paralysis  of  the  veil  of  the  palate  pro- 
duces a  phonetic  trouble;  rhinolalie  ouverte,  or, 
true  nasality  of  tone,  characterized  by  its  exag- 
geration of  the  nasal  resonance;" 

"  (2)  The  immobilization  of  the  veil,  provoked 
by  the  enormous  hypertrophy  of  the  palatine 
(faucial)  tonsils,  or,  by  a  tonsillitis  phlegmon, 
prevents  the  emission  of  the  gutturals,  g,  r,  hard 
g,  r;  that  is  to  say,  the  tonsillitic  voice;" 

"(3)  The  obstruction  of  the  nasopharynx  di- 
minishes and  suppresses  even  the  nasal  resonance, 
creating  a  third  phonetic  trouble,  the  rhinolalie 
ferniee,  or  stoniatolalie,  characterized  by  the  im- 
possibility of  emitting  the  nasal  an,  en,  on;  this 
last    trouble    is   above    all    charged    to    adenoid 


202  THE    TONSILS    AND    THE    VOICE 

growths  and  tumors  of  the  nasopharynx;  finally 
the  pharynx  in  its  entirety  plays  in  the  emission 
of  the  singing  voice,  the  role  of  a  powerful  res- 
onating box,  and  thus  all  the  lesions  of  that 
organ  bring  with  singers,  various  troubles  of 
which  the  princij)al  are  the  alterations  of  the 
timbre  and  the  diminution  of  the  volume  of  the 
voice." 

Frank  E.  Miller  saj^s:  "It  is  especially  the 
structural  differences  between  the  resonant 
cavities  of  individual  singers  that  determine  dif- 
ferences of  timbre  or  quality.  There  are  innum- 
erable timbres  for  the  human  voice,  as  manj^  as 
there  are  voices,  and  all  due  to  the  pliability  of 
the  vocal  tract.  The  walls  of  the  pharynx  are 
permeated  by  a  network  of  muscles,  susceptible 
of  numerous  adjustments  and  re-adjustments  in 
size  and  shape.  So  numerous  are  the  adjustments 
in  shape  of  the  voice  tract  that  Mara  could  make 
one  hundred  changes  in  pitch  between  any  ttvo 
notes  in  her  voice,  and  as  she  had  a  compass  of 
twenty-one  notes,  she  could  produce  no  less  than 
twenty-one  hundred  changes  in  pitch  within  a 
range  of  twenty-one  notes.  It  is  b^^  timbre  that 
we  distinguish  voices  as  we  distinguish  features." 

"There  are  not  such  minute  and  individual 
differences  between  instruments  of  the  same  kind 
as  there  are  between  voices  of  the  same  range,  be- 
cause there  are  no  such  minute  and  individual 
structural  differences  in  instruments  as  in  the 
vocal  organs  of  individuals — differences  that  each 
individual  can  multiply  ad  infinitum  by  the  subtle 
and  delicate  play  of  muscles  acting  in  response  to 
mental  suggestion,  art  sense,  inspiration,  tern- 


THE    SCIENCE    OF    THE    VOCAL  ART  203 

perament,  psychic  impulse  or  whatever  cognate 
term  one  may  choose  to  call  it." 

G.  Hudson-Makuen,  in  The  Transactions  of 
the  American  Laryngological  Association,  1911 
states:  ''There  is  no  absolute  standard  of  vocal 
excellence.  The  voice  that  sounds  good  to  one 
person  may  sound  different  to  another.  Whether 
a  voice  is  good  or  bad  depends,  not  actually  but 
practically,  upon  the  ear  of  the  listener.  This 
fact  may  account,  perhaps,  for  the  great  differ- 
ence of  opinion  now  prevailing  as  to  the  effect  of 
tonsil  operations  upon  the  voice." 

Are  these  statements  the  truth?  Is  it  a  fact 
that  "A  good  or  bad  voice  depends  upon  the  ear 
of  the  listener?"  and  that  "  the  great  difference  of 
opinion  as  to  the  effect  of  tonsil  operations  on  the 
voice  depends  upon  the  differences  in  ears?"  Or 
is  the  alleged  fact  only  an  assumption? 

Is  it  the  mere  faculty  of  hearing,  the  simple 
ear,  that  enables  one  to  judge  the  quality  of  tone; 
that  justifies  the  price  put  upon  the  patrons  of 
grand  opera;  that  moves  the  audience  to  raptur- 
ous applause  of  famous  singers ;  or,  is  it  not  rather 
the  educated  ear  that  reigns  as  an  umpire  in  the 
art  of  song ;  is  it  not  the  cultured  critic  alone,  who 
is  capable  of  perceiving,  analyzing  and  appre- 
ciating the  very  rudiments  of  a  standard  tone  ? 

Is  there  no  standard  in  vocal  excellence,  no 
criterion,  no  aim? 

There  is  no  doubt  that  the  old  Italiaii  singing 
masters  aimed  for  a  standard  tone,  and  taught 
strictly  according  to  correct  physiological  prin- 
ciples. The  old  teachers  insisted  on  a  course  of 
voice  training  which  took  years  to  give  the  stu- 


204  THE    TONSILS    AND    THE    VOICE 

dent  complete  ease  and  perfect  control  of  techni- 
que. 

The  voice  mechanism  is  delicate  and  finely- 
poised.  Slight  physical  disturbance,  or  wrong  use 
of  the  mechanism,  promptly  and  seriously  affects 
the  quality  of  the  voice.  Artistic  singing  depends 
upon  a  correct  method  in  voice  production.  A 
correct  method  consists  of  a  perfect  co-ordination 
of  all  parts  of  the  voice-producing  mechanism, 
an  intricate  and  complicated  apparatus. 

Frank  E.  Miller  says  that  "in  every  voice  cer- 
tain notes  are  better  than  others,  and  a  correct 
method  of  voice  production,  while  it  may  not  be 
able  to  make  every  note  in  the  range  of  the  voice 
of  equal  quality,  brings  the  whole  voice  up  to  a 
more  even  standard  of  excellence.  It  leaves 
the  best  notes  as  good  as  ever  and  brings  the 
notes  which  naturally  are  not  so  satisfactory 
nearer  the  standard  of  the  best.  There  are 
certain  fundamental  lyrinciples  in  a  correct  meth- 
od of  voice  production,  based  upon  study  and 
knowledge  of  the  organs  concerned." 

"Every  vocal  tone  is,  in  fact,  a  mental  concept 
reproduced  as  voice  by  the  physical  organs  of 
voice  production.  That  is  why  an  inaccurate  ear 
for  pitch  results  in  a  vocalist  singing  off  pitch.'' 

"In  1891  I  stated  the  necessity  for  a  standard 
for  tone,  and  had  the  idea  of  constructing  a  voice 
measure.  It  was  to  consist  of  a  combination  of 
a  phonograph,  photograph,  and  a  mechanical  re- 
production of  registration  of  the  vocal  sounds, 
the  combination  so  arranged  as  to  form  a  stand- 
ard for  vocal  tones  to  measure  and  compare  for 
all  time  every  voice  in  the  world." 


THE    SCIENCE    OF    THE    VOCAL  ART  205 

"A  standard  pitch  for  orchestras  was  found  to 
be  absolutely  necessary,  in  order  that  every  com- 
bination of  musical  instruments  might  render 
music  intelligently,  and  with  greater  harmony 
and  without  discord.  The  standard  should  be  as 
nearly  perfect  as  possible." 

''It  is  of  equal  or  greater  importance  that  a 
standard  vocal  tone  should  be  recognized,  and  a 
system  formulated  which  will  enable  singers  to 
acquire  it.  Recognizing  that  the  vocal  tone  of 
Caruso  and  Melba  each  represent  in  the  male  and 
female  voice  the  highest  and  best-  example  of 
tone,  and  approach  perfection  nearer  than  any 
others,  definitely  to  ascertain  and  fix  the  method 
of  producing  these  tones,  making  it  possible  for 
students  and  singers  to  adopt  these  methods  and 
produce  tones  of  precisely  the  same  character,  is 
a  prime  desideratum.  The  waves  of  sound  upon 
a  disc  or  cylinder  as  they  come  from  the  throats 
of  Caruso  or  Melba,  furnish  an  exact  template  or 
model  for  waves  that  should  be  made  by  the  vocal 
utterances  of  the  pupil  in  order  to  produce  this 
perfect  tone.  The  waves  of  sound  as  taken  by  a 
record  from  a  student  will  at  once  disclose 
marked  variations  from  these  pattern  records, 
and  with  the  knowledge  of  the  point  at  which 
these  variations  occur,  opportunity  is  had  for 
modification  or  enlargement  at  these  special  lo- 
calities. When  this  is  done,  further  records  will 
show  a  nearer  approach  to  the  pattern,  and  by 
successive  corrections,  the  pupil  should  be  able  to 
produce  sound  waves  as  nearly  identical  with 
those  of  Caruso  and  Melba  as  is  possible." 

"Phenomenal  voices  always  have  been  rare,  and 


206  THE    TONSILS    AND    THE    VOICE 

doubtless  are  no  rarer  now  than  at  any  other 
period.  At  any  time  any  opera  house  would 
have  been  proud  of  two  such  tenors  as  Caruso 
and  Bond,  and  of  two  such  sopranos  as  Melha 
and  Tetrazzini,  while  there  is  no  period  in  which 
a  Semhrich  would  not  have  been  a  i^ara  avis." 

"What  is  tone  production?  The  very  name 
implies  that  it  is  sound  produced  by  a  mechanism 
of  some  kind.  Therefore,  the  first  thing  to  be 
gathered  from  this  deduction  is  that  if  the  mech- 
anism is  correctly  operated,  of  course,  a  correct 
result  will  be  obtained,  or,  in  other  words,  the 
tone  produced  will  be  a  normal  one." 

''From  the  inception  of  the  vocal  art,  the  world 
has  had  its  Carusos  and  Melhas  to  establish  the 
STANDARD  FOR  TOXE^  but  Until  recently,  the  phy- 
siological process  of  producing  this  tone  has  been 
unknown." 

"Now,  as  tone  is  the  foundation  of  all  singing, 
and  as  this  tone  is  the  thing  of  all  others  for 
which  our  artists  have  ever  been  criticised,  does 
it  not  seem  reasonable  that  there  should  be  and 
is  a  tangible  as  well  as  scientific  means  of  voice 
building,  whereby  all  these  difficulties  can  be 
overcome,  and  the  beauty  of  each  voice  developed 
to  its  highest  possible  degree?" 

"The  time  is  rapidly  coming,  if  not  already 
here,  when  not  only  singers  and  musical  people, 
but  the  general  public,  will  see  the  truth  of  these 
statements.  It  is  not  enough  for  the  teacher  to 
be  able  to  sing  a  correct  tone;  he  must  be  able  to 
show  minutely  in  every  stage  of  development 
from  the  beginning  to  the  most  advanced  stages, 
the  points  of  study  to  be  taken  up" 


THM    SCIENCE    OF    THE    VOCAL  ART  207 

Scripture  {''Researches  in  Experimental  Pho- 
netics,'' 1906)  says:  "The  ear  will  hear  what  it 
expects  to  hear.  The  scientific  man  of  to-day  de- 
mands that  work  with  the  unaided  senses  he  fol- 
lowed up  by  the  methods  of  recording  and 
measuring.  Automatic  records,  experimental 
analysis  and  careful  measurement  must  he  the 
foundation  of  phonetics  as  a  natural  science  J" 

A.  Zund-Burguet  (''Experimental  Researches 
on  the  Timbre  of  the  Nasal  French  Vowels'") 
says:  "Beyond  the  physiological  method,  re- 
searches into  the  timbre  of  the  nasalized  vowels 
could  be  made  by  the  purely  physical  method.  In 
fact,  in  place  of  judging  the  color  of  sounds  ac- 
cording to  the  position  of  the  phonator  organs, 
we  may,  by  the  aid  of  certain  methods,  produce 
an  inscription  of  the  vowels,  and  devote  ourselves 
thereafter  to  the  analysis  of  the  tracings  thus  ob- 
tained. The  celebrated  and  regretted  acous- 
tician, Rudolph  Koenig,  had  inaugurated,  thirty 
years  ago,  the  inscription,  and  following  it,  the 
decomposition  of  the  vowels  by  means  of  mano- 
metric  flames.  M.  M.  Hermann  and  Marichelle 
have  devoted  themselves  to  the  same  researches 
according  to  the  tracings  of  the  phonograph." 

"Helmholtz  and  others,  notably  the  Abbe 
Roussolot,  have  extolled  the  study  of  the  timbre 
of  the  vowels  from  tracings  obtained  by  the  ap- 
plication of  the  graphic  method  of  M.  Marey." 

Mar  age  ("^ Audition  and  Phonationf  1907)  : 
"The  ear  can  hear  three  kinds  of  vibrations: 
noises,  music  and  speech/' 

Marage  ("Photographing  Vibrations  of  the 
Voice")  :  "I  have  had  an  apparatus  constructed 


208  THE   TONSILS   AND   THE   VOICE 

which  permits  of  photographing,  developing  and 
fixing  immediately,  the  vibrations  of  the  voice." 

"I  think  that  this  apparatus  will  be  of  service 
to  professors  of  singing  and  of  elocution  in  en- 
abling them  to  not  only  permit  their  pupils  to 
hear  J  but  to  seei,  the  qualities  and  the  defects  of 
their  voices,  and  to  recognize  their  progress: 
philologists  have  with  this  instrument  a  method 
which  permits  them  to  easily  inscribe  exact 
tracings  of  the  voice  spoken  or  sung  in  different 
languages :  finally,  physicians  have,  with  a  photo- 
graph of  the  voice,  an  indisputable  means  of  con- 
trolling and  causing  to  be  controlled  the  state  of 
the  larynx  of  their  patients  before  and  after  a 
treatment." 

Mar  age  {Photographing  the  Voice  in  Medical 
Practice) :  "Photographing  the  laryngeal  vibra- 
tions permits  us  to  see  in  a  very  clear  manner,  the 
state  of  the  voice  at  the  beginning  and  at  the  end 
of  a  treatment." 

The  foregoing  observations  prove  conclusively 
that  the  faucial  tonsils  are  factors  in  voice  mech- 
anism ;  they  show  definitely  the  degree  of  perfec- 
tion attained  in  the  scientific  notation  by  sight 
and  sound  of  the  action  of  the  mechanism,  and 
they  exhibit  the  value  of  this  registration  in  voice 
culture,  as  well  as  in  the  practice  of  medicine; 
they  suggest  the  difficulties  and  show  the  great 
necessity  of  care  in  the  diagnosis  of  tonsillar  affec- 
tions that  bear  upon  the  mechanism  of  the  voice. 

Robert  and  Sven  Berglund,  Stockholm^  have 
invented  a  new  apparatus,  the  photo graphone, 
which  reproduces  simultaneously  both  sound  and 
action. 


' '-'"^•fi^^/Vr 


i»eif  1 


.'.^VJ4^,j,j^,<: 


^'^^;i' .., 


^^^^'^&'iMtx'!r^ 


B:-?5S'^54j 


-««.^,^^^^ 

''**^-'^^^-;.- 


«tes-i, 


**»»*«» 


Photographs  of  the  voice  in  singing  and  speaking. — Marage. 
1.     Speaking.  2.     Singing. 


THE   SCIENCE   OF   THE   VOCAL  ART  209 

Thomas  A.  Edison  has  invented  a  talking  ma- 
chine that  operates  in  harmony  and  unison  with 
motion  pictures,  called  the  Kinetephone, 

Escat.     ''Role  of  the  Pharynx  in  Audition f* 

"The  auditive  function  has  for  an  essential 
condition  the  integrity  of  the  naso-pharyngeal 
cavity,  and  the  free  functioning  of  the  muscles  of 
the  veil  and  of  the  pharynx." 

Marage.  ('' Photo graphie  des  Vibrations  de  la 
Voiai")  "Photographing  the  Vibrations  of  the 
Voice." 

"(3)  By  photographing  the  vibrations  of  the 
voice,  a  professor  of  elocution  can  recognize  from 
the  foregoing: 

"(a)    The  duration  of  each  vowel." 

"(b)    The  note  on  which  it  is  emitted." 

"(c)    The  constituent  parts  of  each  syllable." 

"For  foreigners  and  deaf  mutes,  we  have  thus 
a  method  of  permitting  them  to  see  their  de- 
fects." 

"(4)  A  professor  of  singing  can  immediately 
cause  a  pupil  to  see  a  scale  which  he  has  just 
sung." 

"(a)  If  he  has  sung  in  time,  for  each  note 
must  have  the  same  duration  and  each  rest,  repre- 
sented by  a  straight  line,  the  same  length." 

"(b)  If  he  sings  true,  for  it  suffices  to  count 
the  number  of  vibrations  per  line  and  multiply  it 
by  n  if  each  second  line  lasts  1/n  of  a  second." 

"(c)   //  his  voice  is  good,  for  the  vibrations 

must  have  a  constant  amplitude,  and  be  regular, 

having  no  traces  in  spindles,  which  indicates  that 

the  voice  trembles." 

.  "(d)   If  he  h^.s  an  insufficient  vital  capacity, 

15 


210  THE    TONSILS    AND    THE  A'OICE 

for  if  the  singer  is  obliged  to  breathe  too  often, 
we  find  the  periods  of  rest  too  long  and  too  fre- 
quent." 

"(e)  If  he  has  good  diction  (declamation)  :  in 
fact,  if  his  diction  is  bad,  there  is  no  proper 
grouping." 

"(f)  If  his  diction  is  good,  each  vowel  should 
have  its  characteristic  grouping  and  the  conso- 
nants should  be  marked  in  the  places  which  they 
should  occupy." 

"(g)  What  the  compass  of  the  voice  is:  we  can 
recognize  it  in  finding  the  lowest  and  the  highest 
note  that  a  singer  can  give." 

"(h)  If  he  has  'holes'  in  his  voice:  then  the 
corresponding  notes  are  short  or  trembling,  or 
without  diction  or  even  nil." 

"Conclusion. — I  think  then  that  this  apparatus 
will  be  of  service  to  professors  of  singing  and  of 
elocution  in  enabling  them  to  not  only  permit 
their  pupils  to  hear,  but  to  see,  the  qualities  and 
the  defects  of  their  voices,  and  to  recognize  their 
progress;  philologists  have  with  this  instrument 
a  method  which  permits  them  to  easily  inscribe 
exact  tracings  of  the  voice  spoken  or  sung  in  dif- 
ferent languages ;  finally,  physicians  have,  with  a 
photograph  of  the  voice  an  indisputable  means  of 
controlling  and  causing  to  be  controlled  the  state 
of  the  larynx  of  their  patients  before  and  after  a 
treatment :  in  many  cases  this  control  will  not  be 
useless  either  to  the  physician  or  the  patient." 

Mar  age.  (La  Photographic  de  la  Voice  dans 
la  Pratique  Medicate.)  Photographing  the 
Voice  in  Medical  Practice. 

"If  in  the  course  of  a  treatment  it  is  indis- 


No.  1  No.  2 

Photographs  of  the  voice  in  medical  practice. — Marage. 

No.  1.     The  note  "  la  "  sung  by  a  larynx  affected  with  the  singer's  nodule,   photo- 
graphed at  different  periods  of  the  treatment.     No.  2.    The  same  note  photographed 
at  the  beginning  and  at  the  end  of  treatment  for  pharyngeal  catarrh. 


THE    SCIENCE    OF    THE    VOCAL  ART  211 

pensable  to  measure  in  a  precise  manner,  the  vari- 
ations of  the  auditive  acuity,  it  is  also  equally  im- 
portant, in  the  same  conditions,  to  inscribe  the 
notes  which  a  diseased  larynx  can  sing." 

"In  a  work  presented  to  the  Academy  of  Sci- 
ences, March  23,  1908,  I  have  described  an  ap- 
paratus which  permits  photographing  the  vibra- 
tion of  the  voice  on  a  strip  of  paper  25  meters  in 
length." 

"I  have  thought  that  this  method  might  be  use- 
ful to  physicians  in  permitting  them  to  recognize, 
and  to  allow  their  patients  to  recognize,  the  state 
of  their  voice  before  and  after  a  treatment." 

"I  have  had  occasion  to  photograph  a  large 
number  of  voices." 

^'^Conclusions.  The  photographing  of  the  lar- 
yngeal vibrations  permits  us  to  see  in  a  very  clear 
manner,  the  state  of  the  voice  at  the  beginning  and 
at  the  end  of  a  treatment;  this  proceeding  is  a 
guide  for  the  practitioner  in  the  progress  of  the 
case  to  be  given  and  in  certain  cases  these  tracings 
would  not  be  useless  to  the  patient  and  to  the  phy- 
sician." 

U.S.  Consul-general,  Edward  D.  Winslow, 
Stockholm,  has  courteously  furnished  me  the 
names  of  Robert  and  Sven  Berglund  (Stock- 
holm), inventors  of  a  new  instrument  called  the 
photo graphone.  This  instrument  reproduces  si- 
multaneously both  action  and  sound.  In  this  in- 
strument, the  human  voice  and  all  other  sounds 
are  perfectly  reproduced  without  any  disturbing 
secondary  sounds.  So  perfect  is  the  reproduction 
of  sounds  with  the  photographone  that  the  in- 
ventor can  distinguish  between  and  actually  read 


212  THE    TONSILS    AND    THE    VOICE 

on  the  curve  the  different  letters  of  the  alphabet, 
and  the  photographic  plate  is  so  sensitive  that  the 
smallest  variations  in  the  voice  can  be  studied. 
The  same  words  uttered  in  the  same  language, 
but  by  another  individual,  appear  diiFerent  in  the 
photographone  script. 

The  great  importance  of  this  method  for  obtain- 
ing linguistical  and  musical  records  is  evident. 
With  the  photographone  it  is  possible  at  one  time 
to  photograph  the  action  as  well  as  the  music  and 
song  and  to  reproduce  the  same  at  one  time.  If 
the  original  music  or  song  should  not  be  strong 
enough  to  fill  a  large  concert  hall  the  sound  can 
be  increased  as  desired.  An  immense  volume  of 
magnified  sound  can  be  reproduced. 

And  it  has  been  suggested  that  this  apparatus 
will  be  of  great  value  at  sea  in  calling  out  the 
names  of  lighthouses.  And  I  believe  that  it  would 
also  prove  a  valuable  equipment  in  various  ways 
for  ocean  steamships. 

Marage.  ( Voix  de  Poitrine  et  Voioo  de  Tete.) 
Chest  Voice  and  Head  Voice: 

"A  subject  determined  may  emit  a  certain 
number  of  notes  which  constitute  the  tessiture  of 
his  voice  •}  to  the  lower  notes  of  that  tessiture  cor- 
responds what  is  called  the  chest  register ;  to  high 
notes,  the  head  register ;  between  these  two  regis- 
ters there  exists  a  passage  more  or  less  marked ;  it 
is  the  mechanism  of  this  passage  that  I  wish  stud- 
ied to-day." 

"(1)  Anatomical  Fact.  All  the  intrinsic  mus- 
cles of  the  larynx  are  innervated  by  the  recur- 
rent; the  two  crico-thyroidians  are  alone  inner- 
vated by  the  external  laryngeal;  they  have  then 


THE   SCIENCE   OF   THE   VOCAL  ART  213 

a  special  independence;  these  two  muscles  make 
the  thyroid  cartilage  see-saw  on  the  cricoid  in 
bringing  together  the  two  cartilages  forward; 
they  are  then  the  tensors  of  the  vocal  cords." 

"(2)  Experimental  Fact.  If,  at  the  moment 
of  passing  from  the  chest  voice  to  the  head  voice, 
there  is  a  sudden  contraction  of  the  crico-thyroid- 
ian,  the  space  comprised  in  front  between  these 
two  cartilages  must  diminish  in  size,  and  we  can 
then  recognize  that  diminution  by  means  of  the 
cardiagraph  of  Marey,  modified  by  Zund-Burg- 
uet." 

"This  instrument  is  placed  on  each  side  of  the 
neck  in  the  space  limited  by  the  thyroid,  the  cri- 
coid and  the  crico-thyroidian  muscle;  these  two 
drums  communicate  with  an  inscriptor  drum  by 
means  of  a  tube  having  a  y-shape." 

''First  case. — There  is  a  very  marked  differ- 
ence between  the  two  registers ;  there  is  then  pro- 
duced a  sudden  contraction  of  the  two  crico-thy- 
roidian muscles." 

''Second  case. — The  passing  of  the  chest  voice 
to  the  head  voice  is  less  marked,  then  the  curve 
rises  little  by  little,  and  with  certain  artists,  it  is 
almost  continuous  without  a  union.  The  crico- 
thyroidian  muscle  may  then  either  suddenly  con- 
tract, or  contract  little  by  little  in  such  a  manner 
as  to  produce  the  progressive  tension  of  the  vocal 
cords.  If,  at  the  same  time,  we  photograph  the 
vibrations  of  the  voice,  not  only  may  we  know  the 
notes  which  belong  to  the  chest  register  and  to 
the  head  register,  but  further  may  determine  the 
missing  notes,  that  is  to  say,  the  holes  in  the  voice. 

"The  professors  have  then  well  observed  this 


214  THE    TONSILS    AND    THE    VOICE 

phenomenon  of  the  transition  due  to  the  contrac- 
tion of  the  crico-thyroidian  muscle,  but  the  names 
chest  voice  and  head  voice  seem  to  be  quite  badly 
chosen,  for  they  may  lead  their  pupils  into  error : 
there  is  only  in  fact  one  voice  to  the  aero-laryn- 
gian  vibration  produced  at  the  level  of  the  glottis ; 
it  would  be  better  to  employ  the  term  low  regis- 
ter and  high  register." 

"The  contraction  of  the  crico-thyroidian  muscle 
is  perhaps  not  the  only  phenomenon  which  is  pro- 
duced at  the  moment  of  passage,  but  it  is  always 
produced  and  it  is  easy  to  put  in  evidence." 

^'Conclusions.  When  the  passage  between  the 
two  registers,  low  or  high,  is  very  marked,  the 
tracing  of  the  vibrations  shows  that  the  voice  is 
tremulous  and  that  certain  notes  are  in  default. 
The  professors  of  singing  have  then  reason  for 
employing  the  methods  which  they  believe  to  be 
useful  to  cause  this  passing  or  transition  to  dis- 
appear." 

Mar  age.  (La  Respiration  chez  les  Chanteurs.) 
The  Breathing  of  Singers: 

"As  Marey  said  a  long  time  ago,  there  is  no 
such  thing  as  masculine  respiration  and  feminine 
respiration;  there  are  good  respirations  and  bad 
respirations." 

"(1)  Good  Respiration.  In  order  that  the 
respiratory  act  be  well  done,  it  is  necessary  that 
the  thoracic  cage  be  dilated  nearly  equally  fol- 
lowing all  its  dimensions.  It  is  further  necessary 
that  the  respiration  be  sufficient,  that  is  to  say 
that  the  vital  capacity  be  in  accord  with  the  age 
and  the  height  of  the  subject." 

"(2)  Bad  Respiration.     Bad  respiration  oc- 


THE    SCIENCE    OF   THE    VOCAL  ART  215 

curs,  when  one  of  the  perimeters,  inferior,  or  su- 
perior, augments  much  more  than  the  others." 

''Exaggerated  augmentation  of  the  inferior 
perimeter.  Occurs  in  men  and  women  of  a  seden- 
tary life;  the  muscles  of  the  abominal  wall  have 
no  longer  the  tonicity  sufficient;  the  diaphragm 
in  contracting,  repels  the  intestinal  mass;  these 
subjects  breathe  with  the  abdomen,  according  to 
the  vulgar  expression." 

"Exaggerated  augmentation  of  the  superior 
thoracic  perimeter.  Occurs,  chiefly,  in  certain 
subjects  much  given  to  sport  and  in  women  who 
wear  corsets,  even  if  not  tight;  the  slightest  ob- 
stacle suffices  in  effect  to  change  the  type  of  res- 
piration. The  muscles  of  the  abdominal  wall 
have  no  longer  any  work  to  perform  since  they 
are  replaced  by  the  corset,  and  allow  themselves 
to  be  repelled  too  easily  by  the  diaphragm  when 
that  obstacle  has  disappeared." 

''Conclusions.  (1)  For  a  respiration  to  be 
good,  it  is  necessary  that  the  thoracic  cage  be 
dilated  following  all  its  dimensions." 

"(2)  In  order  that  it  be  sufficient,  it  is  neces- 
sary that  it  dilates  enough  and  in  such  a  manner, 
as  to  obtain  a  vital  capacity  in  accord  with  the 
age,  the  height  and  the  weight  of  the  subject." 

"  ( 3 )  Each  pupil  of  singing  or  elocution  should 
have  a  respiratory  card  giving  not  only  his 
height,  his  weight,  his  thoracic  perimeter  and 
his  vital  capacity,  but  also  the  curve  represent- 
ing his  class  of  respiration." 

"  (4)  It  is  useless  to  learn  to  sing  or  to  speak  if 
one  does  not  know  how  to  breathe,  and  the  ma- 


216  THE    TONSILS    AND    THE    VOICE 

jority  of  voices  are  lost  not  so  much  through  a 
bad  general  method  as  by  bad  respiration." 

John  Howard,  Harry  Campbell,  Marage,  and 
Koffler,  are  four  great  authorities  on  breathing 
and  thej^  all  agree. 

Marage.  (La  Ported  de  Certaines  Voice  et  le 
Travail  develojjpe  Pendant  la  Phonation.)  The 
reach  of  certain  voices  and  the  energy  developed 
during  phonation: 

"An  orator  is  often  embarrassed,  when  he 
speaks  in  a  room  of  which  he  does  not  know  the 
acoustic  qualities,  to  know  what  energy  he  must 
give  to  his  voice  to  make  himself  heard  by  all  his 
auditors." 

"The  problem  is  quite  complex;  we  have,  in 
effect,  three  factors  which  may  intervene:  the 
room  itself,  the  auditors  and  the  orator." 

"A  room  is  good  if  there  is  no  echo  and  if  the 
resonant  sound  has  a  sufficient  duration  to  rein- 
force the  sound  which  produces  it  without  en- 
croaching upon  the  sound  which  follows." 

"Further,  the  ears  of  the  auditors  are  not 
equally  sensitive  to  all  the  sounds :  to  the  physio- 
logical state  and  in  the  open  air,  low  tones  are 
heard  much  less  easily  than  high  tones." 

"We  have  then  remaining,  the  influence  of  the 
orator." 

"We  say  generally  that  certain  voices  carry  bet- 
ter than  others:  is  this  assertion  true;  what  ex- 
actly does  it  signify?" 

"We  are  therefore  going  to  seek,  in  a  deter- 
mined room,  what  energy  must  be  given  to  his 
voice  to  make  himself  heard,  an  orator,  accord- 


THE    SCIENCE    OF    THE    VOCAL  ART  217 

ing  to  whether  he  has  a  register  of  basso,  barytone 
or  tenor." 

"The  energy  of  the  sound  being  given  by  the 
product  VH  of  the  Volume  V  of  air  which  es- 
capes from  the  lungs  under  a  pressure  H,  the 
question  is  to  determine  these  two  quantities." 

"The  numerous  experiments  on  the  measuring 
of  the  auditive  acuity,  have  proved  to  me  that  the 
synthetic  vowels  ou,  o,  a,  emitted  on  the  same 
note,  fa,  for  example,  common  to  the  registers  of 
basso,  barytone  and  tenor,  produce  the  same  im- 
pression on  the  ear  as  one  of  these  three  voices :  it 
will  be  sufficient  then  for  us  to  employ  successive- 
ly these  three  vowels." 

"We  will  then  seek  the  smallest  amount  of  en- 
ergy necessary  to  cause  one  of  these  sounds  to  be 
heard  by  a  listener  placed  successively  in  differ- 
ent parts  of  the  room." 

"In  the  experiments  made  in  rooms  of  the 
Trocadero,  Chapel  of  the  Sorbonne,  Academy  of 
Medicine,  and  Richelieu  Amphitheatre,  it  is  at 
once  seen  that  in  all  these  rooms  bass  voices  have 
a  great  disadvantage,  since  they  must  employ  an 
energy  7  to  16  times  greater  than  a  tenor  voice: 
the  barytone  voices  are  intermediate,  while  ap- 
proaching much  closer  the  tenor  voice." 

"If  we  consider  the  different  rooms,  a  tenor 
must  expend  four  times  more  energy  in  the  Troc- 
adero than  in  the  Richelieu  Amphitheatre ;  on  the 
contrary,  a  bass  voice  is  obliged,  according  to  the 
room,  to  give  sometimes  an  energy  nine  times 
greater." 

''Conclusions.    Equality  of  Diction.     • 

"  ( 1 )    It  is  right  to  say  that  certain  voices  carry 


218  THE    TONSILS    AND    THE    VOICE 

better  than  others;  this  expression  simply  signi- 
fies that  certain  voices  require  less  effort  to  make 
themselves  heard." 

"  (2)  An  orator  should  develop  V  and  H,  that 
is  to  say,  augment  V  in  increasing  his  vital  ca- 
pacity by  exercise  appropriate  for  the  inspirator 
muscles;  augment  H  in  learning  to  exercise  his 
expirator  muscles;'  and  at  the  same  time  not  al- 
low the  air  to.  be  uselessly  lost  by  the  opening  of 
the  glottis." 

"  (3)  In  practice,  to  make  himself  heard  by  an 
audience  in  an  unknown  room,  it  is  necessary 
to  augment  little  by  little  the  energy  of  the  voice 
until  he  commences  to  perceive  himself  the  sound 
of  the  resonants;  this  diminishes  a  little  the  en- 
ergy of  the  sound  and  will  thus  obtain  the  best 
results." 

"Remarks.  (1)  The  pressure  of  the  air  main- 
tains itself  whether  it  is  an  affair  of  the  natural 
or  of  an  artificial  larynx  between  100  and  200 
millimeters." 

"(2)  That  which  causes  the  energy  of  phona- 
tion  to  vary  enormously  is  the  delivery  of  the  air, 
which  oscillates  from  300  litres  per  hour  ( natural 
larynx,  conversation)  to  2,070  litres  per  hour 
(artificial  larynx,  conversation.)" 

"(3)  The  vocal  cords  not  having  the  same 
length  in  men  (20  to  24  millimeters)  as  in  women 
(16  to  18  millimeters),  I  have  made  experiments 
in  changing  the  length  of  the  vibrating  part  of 
the  membranous  reeds." 

"For  the  long  reeds  (24  mm.)  the  minimum 
energy*  to  make  them  vibrate  is  57  kilogrammet- 
ers  per  hour;  for  the  short  reeds   (18  mm.)    14 


THE    SCIENCE    OF    THE    VOCAL  ART  219 

kgm.,  400.  One  may  then  foresee  that  woman 
fatigue  themselves  much  less  in  talking  than  the 
men;  we  know  also  that  children,  in  whom  the 
larynx  is  still  much  smaller,  can  talk  all  day  with- 
out having  the  air  of  being  in  the  least  tired." 

^'^Conclusions.  ( 1 )  An  orator  must,  before  all, 
learn  to  breathe,  since  it  is  V  which  varies  the 
most." 

" (2)  He  must  not  lose  air  uselessly;  that  is  to 
say,  the  vocal  cords  must  join  on  the  median 
line." 

"(3)  Men,  and  in  particular,  basses,  fatigue 
themselves  much  more  in  speaking  than  women 
and  children." 

''Resume.  During  phonation,  there  escapes 
from  the  lungs  a  certain  volume  of  air  under  a 
certain  pressure;  the  product  of  these  two  quan- 
tities, the  volume  and  the  pressure,  give  the  work 
developed." 

"It  is  a  question  then  to  determine  them." 

"The  volume  of  air  which  escapes  is  obtained 
*  quite  easily,  but  it  is  more  difficult  to  measure  the 
pressure,  for  it  is  necessary  to  take  it  directly  in 
the  trachea." 

"These  difficulties  have  been  surmounted  in 
taking  the  measures  on  two  subjects;  one  was 
furnished  with  an  artificial  larynx  and  the 
other  wore  a  tracheal  canula  and  a  normal  larynx. 
During  ordinary  conversation,  there  is  developed, 
in  one  hour,  an  energy  of  about  48  kilogram- 
meters;  that  is  to  say,  that  to  speak  during  one 
hour  is  not  more  fatiguing  than  to  lift  at  each 
second  a  weight  of  13  grammes,  one  meter  high: 
a  lady  in  trifling  with  her  fan,  or  a  professor  ges- 


220  THE    TONSILS    AND    THE    VOICE 

ticulating  with  a  piece  of  chalk,  exerts  an  energy 
much  greater." 

"To  pronounce  a  discourse  in  a  large  room,  the. 
energy  is  more  considerable,  but  it  is  not  enor- 
mous; it  is,  on  an  average  of  200  kilogrammet- 
ers  per  hour;  an  employee  of  a  railroad  per- 
forms a  greater  work  in  lifting  from  the  ground 
on  to  his  shoulder,  four  packages  of  50  kilo- 
grammes." 

"We  have  compared  subsequently  the  energy 
developed  in  conversing  by  the  voice  of  a  man  and 
that  of  a  woman,  and  have  found  that  women  are 
fatigued,  in  talking,  four  times  less  than  a 
man.  We  can  then  comprehend  how  children  who 
have  a  larynx  narrower  than  their  mothers,  can 
talk  for  several  hours  without  taking  a  rest." 

"The  practical  conclusions  of  these  experiments 
is  as  follows:  The  energy  developed  depends, 
above  all,  on  the  volume  of  air  expirated ;  an  ora- 
tor must  then  learn  to  accumulate  the  air  in  his 
lungs  and  to  not  allow  it  to  escape  uselessly." 

In  the  science  of  the  vocal  art,  there  are  many 
lights  and  side  lights,  of  exceeding  interest,  which 
the  bounds  of  this  book  must  of  necessity  exclude : 
such,  for  example,  as  the  consideration  of  what 
well-informed  teachers  of  voice,  artists,  and  stu- 
dents, should  know  of  the  anatomy  and  physiolo- 
gy of  the  vocal  organs ;  the  measure  for  increasing 
the  volume  of  the  voice,  its  power,  intensity  and 
endurance,  the  means  for  improving  the  purity 
of  tone ;  consideration  of  variations  in  resonance, 
compass,  timbre  and  quality,  advanced  views  re- 
garding pitch,  and  the  sensations  of  audition ;  ex- 
periments in  phonetics;  the  production  of  vowel 


THE   SCIENCE   OF   THE   VOCAL  ART  221 

sounds  by  manikins;  speech  without  a  larynx, 
etc. 

Charles  A.  Rice:  "Vibration  is  tone  production. 
Tone  production  is  vibration.  Vibration  is  the 
cause  of  sensation.  Perception  of  pitch  is  oc- 
casioned by  the  sensation  acting  directly  on  audi- 
tion by  mediate  contact,  and  not  by  listening  with 
the  outer  ear.  Perception  of  pitch  is  due  to  medi- 
ate contact  with  the  nerve  of  hearing,  or  direct 
contact  with  the  sounding  board.  Listening  by 
the  external  ear  is  only  confusion  in  tone  produc- 
tion." 

Mar  age  [Audition  et  Phonation  chez  les 
Sourds-muets) : 

"The  ear  can  hear  three  kinds  of  vibrations: 
noises,  music  and  speech." 

Mar  age  (Theorie  Elementaire  de  V Audi- 
tion) : 

"The  middle  ear  is  filled  with  air  which  com- 
municates with  the  atmosphere  by  a  tube,  the 
Eustachian  tube,  opening  into  the  pharynx:  the 
pressure  is  thus  always  equal  on  the  two  faces  of 
the  tympanum." 

"The  vibrations  of  the  tympanum  are  traversed 
to  the  round  window  by  the  intermediary  of  the 
air,  and  to  the  oval  window  by  the  intermediary 
of  the  chain  of  ossicles." 

"The  internal  ear  is  filled  with  a  first  liquid,  the 
peri-lymph,  which  communicates  with  the  cepha- 
lorrhachidian  liquid  by  a  canal,  the  peri  lymphatic 
canal;  a  membranous  sack,  the  endo-lymphatic 
sack,  is  completely  immersed  in  the  peri-lymph 
and  filled  by  a  second  liquid,  the  endo-lymph 
liquid.     It  is  in  the  midst  of  this  liquid  where  are 


222  THE    TONSILS    AND    THE    VOICE 

found  the  nerve  terminations  of  the  auditory- 
nerve  ;  the  volume  of  the  endo-lymph  is  very  near- 
ly the  third  of  that  of  the  peri-lymph.  We  see  then 
that  the  exterior  vibrations,  before  impressing 
this  nerve,  must  traverse  the  tympanum,  the  chain 
of  ossicles,  the  peri-lymph,  and  the  endo-lymph, 
and  that  everything  is  disposed  in  the  ear,  not  to 
augment  the  intensity  of  the  vibrations,  but,  on 
the  contrary,  to  diminish  them  as  much  as  pos- 
sible." 

"When,  for  any  reason  whatever,  the  chain  of 
ossicles  is  immobilized,  the  chain  of  vibrations  can 
pass  directly  from  the  tympanum  to  the  round 
window  by  the  intermediary  of  the  air  of  the  mid- 
dle ear,  and  if  the  tympanum  itself  is  too  much 
thickened  to  vibrate,  it  suffices  to  pierce  a  hole  in 
order  that  the  vibrations  may  pass  directly  to  the 
ound  window  and  that  the  sound  be  perceived." 

How  does  a  sound  impress  itself  upon  the 
nerve  terminations  ?  There  are  two  theories :  ( 1 ) 
By  Helmholtz.  Each  nerve  termination  of  the 
cochlea  is  influenced,  and  could  not  be  influenced 
except  by  one  sole  sound  of  determined  pitch; 
( 2 )  by  other  authors.  All  the  neiwe  threads  will 
be  equally  impressed,  and  it  will  be  the  different 
nerve  centers  situated  in  the  brain  which  will  re- 
act differently." 

"The  results  of  1,500  measurements  of  auditory 
acuity,  the  observation  of  800  cases  of  deafness 
of  different  kinds,  lead  me  to  suppose  that  this 
second  hypothesis  must  be  admitted." 

Marage,  presented  by  M.  Yves  Delage  {Con- 
tribution a  VEtude  de  V Audition,  October  12, 
1908) : 


THE    SCIENCE    OF    THE    VOCAL  ART  223 

"  ( 1 )  Anatomic  Facts.  The  internal  ear  is  not 
composed  only,  as  is  taught  in  many  classic  works, 
of  vestibule,  of  semi-circular  canals,  and  of  the 
cochlea  with  its  nerve  terminals,  as  found  therein ; 
in  this  term  internal  ear  must  be  comprehended 
the  real  terminations  in  the  brain,  of  the  two 
branches,  vestibular  and  cochlear,  which  constitute 
the  auditory  nerve;  the  vestibular  nerve  which 
corresponds  to  the  anterior  root,  terminates  in  the 
nucleus  of  Deiters  and  in  the  vestibular  nucleus ; 
the  posterior  root,  or  cochlear  nei've  is  much  more 
complex,  and  joins,  by  divers  branches,  to  eight 
different  nuclei.  Bechterew  has  divided  these 
different  branches  into  centripetal  auditory  ways 
of  first  and  second  order,  which  communicate, 
either  among  themselves,  or  directly  with  the 
cochlea,  with  the  different  centers ;  further,  there 
exist  centrifugal  or  recurrent  ways  which  allow 
the  different  cellular  nuclei  to  communicate 
among  themselves." 

"  (2)  Pathological  Facts.  With  the  apparatus 
which  I  have  presented  here,  one  may  now  deter- 
mine exactl}^  the  height,  the  timbre  and  the  ten- 
sity of  sounds,  which  the  ear  may  hear." 

"Results  obtained: 

"(a)  Subjects  are  frequently  met  with  who 
hear  the  most  feeble  noises,  but  who  are  com- 
pletely deaf  as  to  music  and  speech." 

"(b)  Others  are  met  with  who  hear  noises,  mu- 
sic and  speech,  even  to  the  musical  vibrations  pro- 
duced by  the  timbre  of  each  voice,  but  who  do  not 
comprehend  it." 

"(c)  There  exist  other  subjects,  in  whom  deaf- 
ness has  evolved  rapidty,  in  such  a  manner  as  to 


224  THE    TONSILS    AND   THE    VOICE 

become  absolute  in  24  hours ;  in  one  instance,  for 
example,  deafness  is  evolved  in  the  following 
fashion:  the  deafness  began  at  11  o'clock  in  the 
evening,  by  the  disappearance  from  the  hearing 
of  certain  instiTiments  of  the  orchestra,  the  vio- 
lins; 2  hours  afterwards,  no  musical  sound  could 
be  heard,  but  speech  is  very  well  comprehended; 
8  hours  after  the  deafness  is  complete  for  all  vi- 
brations, noises,  music,  speech." 

"(d)  When  the  auditive  acuity  is  developed 
by  appropriate  means,  the  inverse  phenomena  are 
produced;  all  of  the  vibrations  do  not  commence 
to  be  heard  at  the  same  time,  and  the  amelioration 
is  produced  as  if  it  concerned  different  ears  which 
are  not  sensible  to  the  same  sound." 

"Explanation:  These  phenomena  may  be  ex- 
ulained  in  the  following  manner:  when  a  vibra- 
tion of  any  nature  is  produced  at  the  exterior,  all 
the  nerve  terminals  are  impressed  by  the  inter- 
mediary of  the  peri-lymph  and  the  endo-lymph, 
and,  in  case  it  concerns  a  noise,  a  musical  or 
speech  vibration,  it  is  the  nerve  centers  of  the 
first,  second,  or  third  stage  which  are  impressed." 

''The  degree  of  perfection  of  the  hearing  is 
then  connected,  not  so  much  to  the  ear  as  an  or- 
gan than  to  the  auditive  centers ,  and  in  conse- 
quence to  the  brain." 

"Resume.  The  second  theory  of  the  auditory 
centers  is  conformable  to  our  most  recent  ana- 
tomic and  pathologic  knowledge.  Furthermore, 
it  readily  explains  the  phenomena  which  we  ob- 
serve." 

Adolph  Zund-Burguet  (Controle  et  Connexion 
de  V Emission  Vocale) :  "holds  that  the  improper 


THE    SCIENCE    OF    THE    VOCAL  ART  225 

pronunciation  of  words  is  due  to  the  wrong  posi- 
tion of  the  tongue  at  the  moment  of  emission,  and 
that  by  means  of  the  instruments,  which  he  has 
invented  and  herein  describes,  we  may  now,  for 
the  first  time  in  the  history  of  phonetics,  observe 
and  control  the  action  of  the  tongue,  and  thus 
lead  to  a  perfect  emission  and  correct  pronuncia- 
tion of  not  only  French,  but  of  any  other  lan- 
guage." The  article  is  highly  interesting  to  pho- 
neticians. 

A.  Zund-Burguet  (Recherches  Eocperimen- 
tales  sur  le  Timbre  des  Voyelles  Nasales  Fran- 
ciases) :  "It  remains  for  us  to  determine  the  tim- 
bre of  the  four  nasal  vowels  according  to  the  po- 
sition of  the  lips.  Here,  still,  I  will  be  able  to 
employ  the  graphic  method :  I  have  preferred  to 
have  recourse  to  photography." 

"I  have  said  previously  that  beyond  the  physi- 
ological method,  researches  into  the  timbre  of  the 
nasalized  vowels  could  be  made  by  the  purely 
physical  method.  In  fact,  in  place  of  judging 
the  color  of  sounds  according  to  the  position  of 
the  phonator  organs,  we  may,  by  the  aid  of  cer- 
tain methods,  produce  an  inscription  of  the  vow- 
els, and  devote  ourselves  thereafter  to  the  anal- 
ysis of  the  tracings  thus  obtained." 

Adolph  Zund-Burguet.  (La  Reeducation  Au- 
ditive d'apres  la  Methode  Electro-V ociphon- 
ique)  : 

"We  had  no  trouble  in  recognizing  that  the  su- 
periority of  the  oral  method,  over  other  methods 
of  auditive  re-education,  resides  principally  in  the 
physical  nature  of  the  sounds  of  the  human  voice. 
In  the  case  of  a  correct  emission,  these  are  char- 

16 


226  THE    TONSILS    AND    THE    VOICE 

acterized  by  a  great  richness  in  low  harmonics, 
and  the  absence  of  all  noise." 

"To  create  an  instrument  capable  of  producing 
low,  medium  and  high  sounds,  and  possessing  the 
characteristics  of  the  sound  of  the  human  voice, 
was  only  to  solve  half  of  the  problem  presented. 
To  solve  it  entirely,  it  was  necessary  to  find  a 
means  of  modifying  at  will  their  intensity,  with- 
out changing  at  the  same  time  their  musical  pitch, 
and  also  inversely,  to  be  able  to  vary  the  pitch 
while  conserving  the  intensity.  The  discovery  of 
a  new  principle,  led  to  the  creation  of  an  instru- 
ment until  now  unknown,  and  with  it,  the  com- 
plete realization  of  our  dream." 

"This  instrument  we  call  the  Electro-Voci- 
phone.  It  contains  three  organs,  producers  of 
sounds  very  rich  in  harmonics,  free  from  all 
noises,  and  so  like  the  sound  of  the  human  voice 
that  it  is  only  necessary  to  pass  the  sounds  through 
an  appropriate  resonator,  to  transform  them  at 
once  into  vowels." 

"Technic.  After  having  determined  in  any  usu- 
al way  the  auditive  acuity  of  each  ear  to  be  re- 
educated, we  sound  the  entire  series  of  tones  in 
passing  from  the  low  to  the  high,  or  inversely :  at 
the  same  time  insisting  on  the  sounds  that  the  ear 
perceives  the  least  easily." 

J.IIelsmoortel  (La  Surdite  d'OrigineSclereuse 
et  la  Reeducation  Auditive  par  le  Methode  voci- 
pJionique.  Deafness  of  Sclerotic  Origin  and 
Auditive  Reeducation  by  the  Vociphonic 
Method)  : 

"In  1903,  in  the  course  of  the  meeting  of  the 
Belgian  Otological  and  Larjmgological  Society, 


THE    SCIENCE    OF    THE    VOCAL  ART  227 

Professor  Eeman  of  Gand  declared  that  we 
know  no  means  of  acting  on  this  process.  The 
usual  means  remain  without  effect.  Local  me- 
chanical means  only  aggravate  the  malady  and 
precipitate  its  progress.  Dr.  Le?'moyez  sub- 
scribed without  reserve  to  that  declaration,  and 
the  greater  part  of  the  otologists  present  were  of 
the  same  opinion.  We  held  that  opinion  until  the 
beginning  of  1909,  when  happy  circumstances 
permitted  or  obliged  us,  to  modify  totally  our 
opinion.  It  will  not  be  found  extraordinary  that 
we  have  changed  our  opinion  on  the  intractibility 
of  sclerotic  deafness." 

"We  have  presented  a  number  of  cases  of  scle- 
rotic deafness  greatly  ameliorated  by  re-educa- 
tion, at  the  meeting  of  the  Society  of  Otology  and 
Laryngology  at  Brussels,  in  1909,  and  on  two  oc- 
casions to  the  Medical  Society  of  the  Louise- 
Marie  Hospital,  at  Antwerp." 

"The  apparatus,  invented  by  M.  Zund-Burg- 
uet,  called  Vociphone,  or  Electrophone,  contains 
the  producing  organs  of  sounds  which  correspond 
to  the  three  human  registers,  low,  medium  and 
high.  The  timbre  of  the  sounds  is  entirely  similar 
to  that  of  the  human  voice." 

"By  the  sole  aid  of  the  electrophone  or  voci- 
phone, it  becomes  extremely  easy  to  fulfill  all  the 
conditions  exacted  and  the  recital  of  the  clinical 
observations  will  permit  you  to  judge  of  the  effi- 
ciency of  this  new  method,  of  auditive  re-educa- 
tion in  the  case  of  progressive  deafness  of  scle- 
rotic origin;  that  is  to  say,  in  the  precise  cases 
where  medico-chirurgical  methods  are  absolutely 
powerless.  The  results  obtained,  to  our  surprise, 


228  THE    TONSILS    AND    THE    VOICE 

have  not  only  been  integrally  maintained,  but,  in 
the  majority  of  cases,  have  been  considerably 
augmented  during  the  period  of  repose." 

A.  Raoult.  (Reeducation  de  VOuie  par  le 
Procede  Electro-Phono'ide.  Re-education  of  the 
Hearing  by  the  Electro- phonoid  Method.) 

He  was  at  first  extremely  skeptical  of  the  proc- 
ess, but  has  since  tried  it  in  some  50  cases  with 
great  success,  and  is  now  completely  in  favor 
of  it. 

After  reciting  cases,  with  details,  he  says : 

"In  conclusion,  that  which  gives  an  entirely 
special  value  to  the  electro-phonoid  process  of  re- 
education, is  the  persistence  of  the  amelioration 
of  the  hearing  even  when  the  treatments  are  fin- 
ished and  the  patients  left  in  repose.  Helsmoor- 
tel  has  related  several  observations  of  patients 
seen  a  year  after  the  re-education,  and  in  whom 
the  amelioration  had  persisted." 

"Summary:  From  the  observations  of  all  these 
facts,  we  may  conclude: 

"(1)  Even  in  cases  of  advanced  sclerosis  in 
the  aged,  we  may  still  hope  to  obtain  ameliora- 
tion." 

"(2)  The  amelioration  is  much  more  notice- 
able in  the  young,  and  even  more  when  the  evolu- 
tion of  the  oto-sclerosis  is  less  remote." 

"  (3)  The  verification  in  patients  of  the  abnor- 
mal paracousis  of  Willis  or  that  of  Rinne  seems 
to  make  it  our  duty  to  prognosticate  a  notable 
amelioration  of  deafness." 

"One  great  value  of  the  highly  important 
method  of  auditive  re-education  of  Zund-Burguet 
and  Helsmoortel  will  be  that  of  enabling  the  voice 


THE    SCIENCE    OF    THE    VOCAL  ART  229 

user,  especially  the  singer,  to  again  be  able  to  per- 
ceive his  proper  vocal  pitch." 

Marcel  Natier  {Reeducation  Methodique  de 
JL' Oreille  par  des  Exercises  Acoustiques)  states 
that  he  has  had  great  success  in  the  re-education  of 
the  ear  by  acoustic  exercises  with  diapasons  (large 
tuning  forks). 

Marcel  Natier  {Surdite  et  Altitude.  Re- 
education Methodique  de  V Oreille) :  Details  cases 
of  deafness  which  were  greatly  helped  by  living 
in  the  mountains  at  a  height  of  625  to  900  yards. 
He  simply  records  the  success  of  altitude. 

J.  W.  Gleitsmann  {Ueber  Pharynocstimme, 
1909)  : 

"The  first  patient  who  could  phonate  after  the 
extirpation  of  the  larynx  was  presented  to  the 
Medical  Society  of  Greifswald,  1888,  and  to  the 
Medical  Society  of  Berlin,  1893,  by  Dr.  Schmid, 
B.  Frdnkel  gave  the  correct  explanation.  One 
year  and  six  months  after  removal  of  the  larynx, 
the  man  could  speak  with  a  harsh,  monotonous 
voice.  The  second  case  was  that  of  J.  Solis- 
Cohen,  in  April,  1892.  He  was  presented  to  the 
Medical  Society  of  Philadelphia  in  October, 
1893.  He  could  talk  well  and  modulate  his 
voice.     Heard  40  feet  away." 

"Two  cases  reported  by  Dr.  Gottstein  (1909). 
First  patient,  Gottstein  was  going  to  provide  with 
a  pharyngeal  voice.  Was  given  exercises.  Re- 
turned in  four  months,  with  a  plain  voice.  After 
two  other  lessons,  he  could  modulate  his  voice  and 
even  sing  a  song.  What  Gottstein  accomplished 
with  this  man  in  about  one  year,  he  did  with  an- 


230  THE    TONSILS    AND    THE    VOICE 

other  patient  in  six  weeks.  This  second  one  spoke 
in  a  hoarse  voice,  but  plain  and  distinct." 

"The  systematic  perfection  and  scientific  de- 
velopment of  the  method  is  due  to  GutzinannJ" 

"Such  a  voice  can  be  acquired  on  two  condi- 
tions: the  first  in  an  air  chamber  in  the  hypo- 
pharynx,  generally,  created  by  the  free  will  of  the 
patient,  and  second,  a  little  narrow  space  above 
the  air  chamber,  which  must  be  such  that  the  emis- 
sion of  air  into  the  folds  of  the  mucous  membrane 
may  cause  vibrations  which  are  able  to  produce  a 
real  tone.  Gutzmann  says  that  there  cannot  be 
a  general  rule  about  the  place  where  the  voice  is 
formed ;  it  depends  entirely  on  the  mechanical  con- 
ditions created  by  the  laryngectomy  in  every  case 
respectively."  And  I  will  add  to  the  statement 
of  Von  Gutzmann,  no  vibration^  no  voice. 

Von  Gutzmann,  in  his  work,  "Stimme  und 
Sprache  oJine  Kehlkopf"  makes  the  remarkable 
statement  that  "if  he  can  teach  those  who  have 
no  larynx  to  talk  and  sing,"  that  "he  can  himself 
also  talk  and  sing  without  using  his  larjmx."  He 
has  explained  the  mechanism  by  which  he  accom- 
plishes this. 

He  states  that  he  can  talk  and  sing  and  whistle 
with  absolutely  no  air  passing  out  of  his  larynx. 
"Whistling  with  the  closed  larynx  is  not  hard 
at  all.  I  can  whistle  and  speak  with  the  closed 
larynx;  without  using  my  larynx.  I  am  able  to 
speak  in  a  way  that  my  breathing  is  absolutely 
suspended." 

To  preserve  the  voice,  composers  must  write  for 
the  voice.  Much  of  the  music  written  for  orches- 
tration effects  is  ruinous  to  the  voice.     Artists 


THE    SCIENCE    OF    THE    VOCAL  ART  231 

should  never  attempt  to  sing  music  which  makes 
the  human  voice  secondary  to  orchestral  instru- 
mentation. The  human  voice  is  the  most  sublime 
instrument^  and  should  forever  demand  music 
written  for  the  voice. 

Artists  w  ould  soon  bring  composers  to  a  sense 
of  realization  of  their  fault,  if  they  would  refuse 
to  sing  music  written  chiefly  for  orchestration. 
And  good  voices  would  be  saved. 

The  most  wonderful  singing  voices  in  the  world 
to-day  are  being  produced  in  America.  And  there 
are  in  America  teachers  of  song  as  capable  as  any 
that  live  in  any  country.  There  are  many  cogent 
reasons  why  the  art  of  song  should  take  on  new 
life  and  flourish  in  America.  Art  must  be  pur- 
sued for  Art's  sake. 

Mme.  Cappianij  in  her  excellent  work,  "Prac- 
tical Hints  and  Helps  for  Perfection  in  Sing- 
ing," asks  the  question:  "Why  are  so  many 
voices  ruined  in  Europe?  If  we  consider  what 
regiments  of  students  have  for  the  past  thirty 
years  been  going  to  Europe,  and  how  few  good 
voices  return,  we  are  appalled." 

Henry  W.  Savage  (Opera  and  the  American 
Singer.)  (Monthly  Section,  Pittsburgh  Dis- 
patch, July  10,  1910),  says:  "The  transatlantic 
steamers  sailing  from  American  ports  during  the 
months  of  June,  July  and  August  bear  from 
our  shores  many  thousands  of  American  girls 
going  to  study  music  in  Europe.  And  only  in 
rare  instances  is  it  true  that  the  outward-bound 
student  has  exhausted  the  facilities  and  the  op- 
portunities for  study  which  are  being  left  behind, 
at  home.     We  have  in  this  country  the  finest  mu- 


232  1HE   TONSILS   AND   THE   VOICE 

sical  talent  in  the  world.  'The  finest  voices  in  the 
world  come  from  America,  the  biggest,  the 
purest,  the  most  dramatic,'  said  Jean  de  Reszke 
to  me.  'The  very  best  singers  in  the  world  come 
from  America,'  said  Tito  Ricardo,  of  IMilan,  to 
me.  He  is  regarded  as  an  authority  of  the  high- 
est rank." 

"I  often  wish  that  I  could  go  into  the  homes  of 
these  girls  and  talk  things  over  with  them  and 
their  families.  I  should  like  to  persuade  fathers 
and  mothers  of  the  folly  of  the  idea  that  it  is 
fashionable  to  send  their  daughters  to  Europe 
for  a  musical  education,  to  explain  to  them  that 
the  necessities  for  this  course  have  long  since 
ceased  to  exist,  and  to  focus  their  attention  upon 
the  fact  that  home  institutions  are  offering  facil- 
ities equal  to  those  of  Continental  schools,  and  at 
a  much  smaller  cost." 

"'Let  the  American  pupil  i^emain  at  home, 
where  the  American  voice  can  he  better  handled 
than  on  the  Continent,  because  it  is  better  under- 
stood. American  institutions  offer  splendid 
courses  in  the  techfiology  of  music.  The  best 
of  vocal  training  may  be  received  here." 

Students  from  abroad  now  come  to  New  York 
for  musical  education.  Mme.  Mott  can  verify 
this  statement. 

In  Paris,  the  American  singer  is  looked  upon 
as  a  "good  thing"  to  be  exploited. 

A  long  list  of  brilliant  American  trained  ar- 
tists have  succeeded  in  opera,  here  and  abroad, 
including  Putnam  Grisxscold,  Frances  Maclen- 
nan,  Vernon  Stiles,  Florence  Easton,  Gertrude 
Rennyson,    William  Wegener,  William  Miller, 


THE    SCIENCE    OF    THE    VOCAL  ART  233 

Yvonne  de  Treville,  Edward  Lanhow,  Harriet 
Behnee,  Marion  Ivelle,  Ellison  van  Hoose,  Clar- 
ence Whitehill,  Alfred  Picaver,  Robert  Kent 
Parker,  Marion  Weed,  Florence  Wickhain,  Olive 
Fremstadj  Edith  Walker j  Bessie  Abbot  and 
Geraldine  Farrar. 

Frank  E,  Miller  (The  Voice):  "There  is 
one  great  singer,  Lillian  Nordica,  who  knows  to 
whom  to  give  credit  for  that  skill  in  voice-pro- 
duction which  enables  her  to  sing  Valentine,  Aida 
and  Isolde  with  equal  success.  Her  voice-pro- 
duction she  acquired  not  from  Madame  This  or 
Signor  That,  but  from  plain  John  O'Neill,  of 
Boston,  and  she  took  good  care  not  to  allow  any 
other  teacher,  however  'famous'  to  undo  the 
work  of  the  man  who  had  taught  her  voice-pro- 
duction based  on  correct  knowledge  of  the  physi- 
ology of  the  voice-producing  organs." 

David  Bispham  {"Why  We  Should  Sing  in 
English/'  Century  Magazine,  July,  1910),  says: 

"For  singing  there  is  nothing  difficult  about 
English;  it  is  just  as  easy  as  any  other  language. 
Are  not  its  vowels  the  same — its  consonants  ?  Are 
not  its  words  softer  than  German,  and  easier  to 
pronounce  and  more  rotund  than  French?  Is 
it  not  as  noble  as  Italian?  All  the  arguments 
against  it  emanate  from  those  who  do  not  know 
it,  or  how  to  pronounce  it  either  in  song  or 
speech." 

"Though  we  formerly  imported  singers,  it  is 
obvious  that  we  need  do  so  no  longer.  Soon  we 
can — indeed,  we  do  already — export  artists." 

"When  will  the  scales  drop  from  the  mana- 
gerial eyes,  and  Americans  get  their  chance  here 


234  THE   TONSILS   AND   THE   VOICE 

in  the  same  minor  parts  that  at  first  they  have  to 
take  abroad?" 

"If  they  can  work  and  grow  famous  there, 
they  can  do  here  just  the  same." 

Richard  Mansfield  said,  "America  has  become 
too  great,  and  its  influence  abroad  too  large,  for 
us  to  afford  to  have  recourse  to  that  ancient  and 
easy  method  of  criticism  which  decries  the  Amer- 
ican and  extols  the  foreign." 

This  is  true  indeed. 

Frank  E.  Miller  {The  Voice),  states: 

"  'The  English  language  is  probably  the  one 
that  has  been  described  by  foreigners  as  the  most 
unfit  for  singing.  Greater  calumny  has  never 
been  uttered.  I  contend  for  just  the  opposite: 
that  English  is  the  very  best  language  for  an  ar- 
tistic singer  to  use  for  it  contains  the  greatest 
variety  of  vocal  and  aspirate  elements,  which  af- 
ford an  artistic  singer  the  strongest,  most  natural 
and  expressive  means  of  dramatic  reality.  The 
English  language  has  all  the  pure  vowels  and 
vocal  consonants  of  the  Italian ;  and  besides,  it  is 
full  of  rich  elements,  mixed  vowels,  diphthongs 
and  an  army  of  vigorous  aspirants.'  " 

Tosi  (Italian  School  of  Florid  Song,  1743), 
says : 

"After  having  corrected  the  pronunciation,  let 
him  take  care  that  the  words  be  uttered  in  such  a 
manner,  that  they  be  distinctly  understood,  and 
no  one  syllable  be  lost;  for  if  they  are  not  dis- 
tinguished, the  singer  deprives  the  hearer  of  the 
greatest  part  of  that  delight  which  vocal  music 
conveys  by  means  of  the  words.     For,  if  the 


THE    SCIENCE    OF    THE    VOCAL  ART  235 

words  are  not  heard  so  as  to  be  understood,  there 
will  be  no  great  difference  between  a  human  voice 
and  a  hautboy.  This  defect,  though  one  of  the 
greatest,  is  nowadays  more  than  common,  to 
the  greatest  disgrace  of  the  professors  and  the 
profession." 

Salvatore  M archest  (Vademecum)  states  that: 

"It  is  wholly  erroneous  to  argue  that  there  is 
a  peculiar  Italian,  French,  German  or  English 
method  of  singing.  There  is  only  a  single  aes- 
thetic style  in  music  throughout  the  civilized 
world,  as  well  as  a  single  singing  method,  and  that 
is  the  good  one,  in  the  pure  and  artistic  conception 
of  the  term." 

Mme.  Mathilde  Marchesi  (Method  of  Singing) 
says: 

"People  often  speak  of  the  Italian,  French  or 
German  School  or  Style  of  Singing.  Having  re- 
sided for  many  years  in  the  different  centers  of 
these  three  nationalities,  I  can  safely  say  that, 
with  the  exception  of  national  songs  of  a  popular 
and  local  character,  peculiar  to  each  nation,  there 
are  only  two  vocal  schools  in  the  whole  world: 
the  good,  from  which  the  best  results  are  ob- 
tained; and  the  had,  in  which  the  reverse  is  the 
case.  The  same  may  be  said  with  regard  to  style. 
It  is,  therefore,  quite  a  mistake  to  speak  of  a  Ger- 
man, English,  French  or  Italian  Vocal  School  or 
Style." 

Whether  you  learn  to  sing  in  Italy,  France, 
Germany,  or  America,  the  physiology  of  singing, 
like  the  physiology  of  digestion,  is  always  the 
same.  The  process  of  digestion  is  the  same,  no 


236  THE    TONSILS    AND    THE    VOICE 

matter  where  you  eat  the  food.  The  process  of 
singing  is  the  same,  no  matter  where  j^ou  learn  it. 
There  is  no  Italian  physiology,  no  German  physi- 
ology, no  French  physiology — it  is  all  human 
physiology.  ^ 

Whether  you  are  taught  singing  in  Naples,  by 
Sehastiani,  in  Milan,  by  Sabatini,  in  London,  by 
Shakespeare  or  Santley,  in  Berlin,  by  Mme.  Leh- 
mann,  in  Paris,  by  De  Reszke,  in  New  York  by 
Mme.  Mott,  Mme.  von  Klenner,  George  Sweet, 
or  Rice,  in  Boston,  by  Hubbard,  Mme.  Everett 
or  Mme.  Clara  Kathleen  Rogers,  the  physiology 
of  singing  is  identical. 

History  will  probably  show  that  the  very  best 
in  art  and  the  names  of  the  greatest  artists  only 
of  all  periods  have  been  selected  for  the  preserva- 
tion of  the  ages.  Thus,  by  comparison,  one  is 
led  to  think  that  art  and  artists  of  the  present  time 
are  not  so  great  as  those  of  the  past.  But  I  hold 
no  such  opinion.  Masters  of  art  (in  speech  and 
song)  have  passed  away.  Masters  are  passing 
away.   Great  masters  of  the  art  remain. 

"The  best  traditions  of  the  art  of  singing  are, 
with  very  few  exceptions,  nearly  lost  J"  (Salva- 
tore  Marchesi.) 

Exceptions  prove  that  the  art  is  not  lost. 

It  should  be  remembered  that  in  the  old  daj^s, 
from  which  traditions  of  phenomenally  high 
voices  have  come  down  to  us.  musical  pitch  was 
lower  than  it  is  now. 

Phenomenal  voices  always  have  been  rare. 

At  no  other  time  in  history,  of  which  I  have 
any   knowledge,   has   there   been   such   general. 


THE    SCIENCE    OF    THE    VOCAL  ART  237 

powerful  and  international  educational  co-opera- 
tion as  now.  Ambassadors  of  education,  in  the 
form  of  exchange  professors,  are  now  sent  from 
the  United  States  to  Germany,  Sweden,  Den- 
mark, France  and  Japan.  Never  before  has 
there  been  such  a  world-wide  uplift  in  the  spread 
of  enlightenment  in  science,  art  and  general  cul- 
ture. Never  before  has  money  been  so  lavishly  and 
universally  expended  in  the  pursuit  of  science,  art 
and  education.  The  establishment  of  the  Kaiser 
Wilhelm  professorship  at  Columbia  University, 
and  the  Roosevelt  professorship  at  Berlin  Uni- 
versity, six  years  ago,  was  the  beginning  of  this 
universal  uplift.  The  regents  of  Oxford  Univer- 
sity, following  in  the  wake  of  the  establishment  of 
these  international  professorships,  made  a  ruling, 
in  1909,  "that,  the  students  of  Columbia  Univer- 
sity in  the  freshman  class  shall  be  admitted  to 
Oxford  freshman  class:  that  students  at  Colum- 
bia in  the  sophomore,  junior  and  senior  classes, 
shall  be  admitted  to  Oxford's  semester  classes  on 
a  parity." 

There  never  was  a  time  when  money  was  more 
lavishly  spent  than  now  to  further  the  ends  of 
education,  of  science,  of  art,  and  of  all  that  con- 
tributes to  the  highest  and  most  stable  civilization. 

True  art  is  built  on  firm  foundations ;  its  mas- 
tery requires  intelligent  comprehension,  conscien- 
tious application,  and  an  abundance  of  hard  work 
long  continued.  High  art  is  maintained  by  high 
ideals.  High  ideals  require  strength  in  the  char- 
acter of  the  votaries. 

The  first  signs  of  depreciation  in  any  art  is  per- 
peptible  in  the  lowering  of  the  ideals. 


238  THE    TONSILS    AND    THE    VOICE 

True  art  is  always  pure  art.  Venal  considera- 
tions always  disfigure  and  destroy. 

England  once  led  the  world  in  music.  Italy 
has  passed  her  zenith.  America^  replete  with 
native  artists,  and  with  abundant  means  appar- 
ently stands  upon  the  threshold  of  the  world's  new 
era  in  the  progress  of  music. 


THE   SCIENCE   OF   THE   VOCAL  ART  239 

Letter  of  Mme.  Cappiani. 
Question  1. 

Are  the  normal  faucial  tonsils  of  any  use  to 
singers  ? 

By  the  term,  normal  faucial  tonsils^  I  mean 
the  tonsils  situated  in  the  fauces,  between  the 
anterior  and  posterior  palatine  arches,  in  healthy 
condition,  of  almond  shape,  and  of  such  size  as 
not  to  project  beyond  the  lines  of  the  palatine 
arches,  nor  press  upon  surrounding  tissues,  upon 
the  superior  constrictor,  the  palato-glossus  or 
palato-pharyngeus  muscles,  of  a  size  so  small  as 
not  to  interfere  with  the  perfect  anatomical  out- 
lines of  the  walls  of  the  pharynx. 

Answer.  Certainly,  they  are  necessary  for  the 
acoustics  of  the  voice,  the  sounding  board  of 
which  is  in  the  nasal  bridge  where  from  all  the  fa- 
cial bones  connected  with  each  other  are  awakened 
to  resound  to — which  by  their  different  shapes 
give  different  tones,  forming  a  kind  of  accord 
to  the  one  tone  we  produce.  These  vibrations  to- 
gether beautify  the  voice  in  sympathy  and  gran- 
deur and  give  the  individual  ''timbre  de  la  voice/' 

Question  2.  How,  or  in  what  manner  are  they 
of  use  to  singers,  already  described? 

Answer.  If  tonsils  are  cut  out,  it  wants  con- 
siderable skill  to  bring  the  vibrations  of  whatever 
tone  up  in  the  nasal  bridge,  as  they  come  too  easily 
from  the  larynx  through  the  mouth  to  the  listen- 
er in  a  harsh  or  vulgar  tone  without  that  sympa- 
thy above  described,  when  all  the  facial  bones  are 
awakened  to  resonance. 

Question  3.  Do  you  personally  know  of  any 


240  THE    TONSILS    AND    THE    VOICE 

instance  or  instances,  in  which  a  singer's  voice 
was  improved  after  removal  of  normal  tonsils? 

Answer.  No!  But  the  voice  may  be  changed 
to  higher  or  lower  pitch  by  the  cicatrization  and 
the  Chirurgeon  can  not  know  beforehand  which 
way  the  result  may  be.  Often  the  compass  of  the 
voice  may  not  be  changed  at  all ;  only  the  sound- 
ing quality  made  more  ordinary. 

Question  4.  Do  you  personally  know  of  any 
instance  or  instances  in  which  a  singer's  voice 
was  impaired  or  ruined  after  the  removal  of  nor- 
mal tonsils? 

Answer.  A  singer's  voice  cannot  be  entirely 
ruined  by  cutting  out  the  tonsils.  It  is  too  great 
a  distance  from  the  tonsils  to  the  vocal-bands  in 
the  larynx. 

Question  5.  Would  you,  as  a  rule,  advise  the 
removal  of  normal  tonsils  in  singers? 

Answer.  No.  Only  in  cases  of  diseased  and 
so  swollen  tonsils  that  danger  of  suffocation  is 
near.  Then  they  must  be  cut  out — as  it  is  better 
to  lose  one's  tonsils  than  one's  life. 

LuiSA  Cappiani. 


^ 


^  J  5  ,e  ^ 


"=^-^ 


CHAPTER  X 
SIX  VOICE  QUESTIONS. 

Question  Number  One. 

Are  the  normal  faucial  tonsils  of  any  use  to 
singers  ? 

By  the  term,  normal  faucial  tonsils,  I  mean  the 
tonsils  situated  in  the  fauces,  between  the  an- 
terior and  posterior  palatine  arches,  in  healthy 
condition,  of  almond  shape,  and  of  such  size  as 
not  to  project  beyond  the  lines  of  the  palatine 
arches,  nor  press  upon  the  surrounding  tissues, 
upon  the  superior  constrictor,  the  palato-glossus, 
or  palato-pharyngeus  muscles,  of  a  size  so  small 
as  not  to  interfere  with  the  perfect  anatomical 
outlines  of  the  walls  of  the  pharynx. 

George  A.  Sweet:  "No." 

Mnie.  Marie  Olive  Fremstad:  "No." 

Vincenzo  Sahatini:  "I  do  not  know." 

Bond:  "I  do  not  think  so." 

S.  S.  Curry:  "None  that  I  have  ever  been  able 
to  trace." 

David  Bispham:  "I  do  not  know  from  my 
own  experience,  as  I  have  never  had  trouble  with 
my  tonsils." 

Mme.  Clara  Kathleen  Rogers:  "Normal  fau- 
cial tonsils  have  no  direct  use  in  singing." 

Charles  A.  Rice:  "The  normal  tonsils  are  of 
no  use  to  singers  in  tone  production,  nor  in  giv- 
ing assistance  to  the  quality  of  the  voice." 

David  C.  Taylor:  "No,  not  of  direct  use  in  the 

17  241 


242  THE    TONSILS    AND    THE    VOICE 

conduct  of  the  voice.  Their  functioning  is  no 
doubt  an  item  in  the  general  vitaUty,  but  this  is 
not  specifically  a  matter  of  voice." 

Frederick  E.  Bristol:  "I  cannot  say  if  the 
normal  tonsils  are  of  any  particular  use,  or  in 
other  words,  if  they  have  any  function,  as  re- 
gards the  proper  emission  of  the  voice.  I  have 
never  seen  that  they  are  an  obstacle  and  have 
never  advised  their  removal." 

George  Fergusson:  "I  consider  it  impossible 
for  singers  or  teachers  to  state  definitely  the  use 
of  the  tonsils  to  the  singer." 

Mvie.  Irene  San  Carola:  "I  hold  that  one  of 
the  most  important  functions  of  the  singer's  art 
is  to  produce  for  the  voice  a  perfectly  free  pas- 
sage, through  the  pharynx,  to  all  resonators.  In 
my  opinion,  therefore,  no  part  of  this  passage 
can  be  of  any  use  to  the  singer  except  in  a  nega- 
tive sense,  i.e. :  in  its  capability  of  being  kept  out 
of  the  way.  Xormal  tonsils  can — and  should — 
be  rendered  nugatory  by  muscular  exercise  as 
exemplified  in  yawning." 

Mme.  Lillian  Nordica:  "My  tonsils  being 
very  small  are  perfectly  healthy.  I  have  never 
realized  that  they  have  played  any  special  part 
in  singing." 

Charles  A.  White:  "A\nio  knows ?" 

William  Shakespeare:  "I  believe  no  one  knows 
what  the  functions  of  the  tonsils  really  are." 

Mme.  Lilli  Lehmann:  "I  do  not  believe  that 
anyone  can  answer  this  in  the  right  way." 

Sir  Charles  Santley:  "I  am  not  prepared  to  say 
the  tonsils  are  of  any  use  to  singers,  especiallj'-, 


SIX   VOICE    QUESTIONS  243 

but  that  they  are  of  use  is  certain  or  they 
would  not  exist." 

Carlo  Sebastiani:  "Anything  belonging  to  our 
organism  has  its  function,  and  its  proper  reason 
to  exist.  Only  the  excess  or  the  deficiency  of  any 
part  whatsoever  can  be  of  detriment  to  the  or- 
ganism. As  to  the  first  part  of  this  question,  the 
normal  tonsils  they  might  perhaps  be  of  utility 
to  the  voice,  to  modify  the  resonance,  and  the 
timbre.    Though  it  is  not  proven  by  me." 

Richard  Loewenherg:  "To  prevent  misunder- 
standing by  'normal'  tonsils,  I  mean  tonsils  of  a 
healthy  color,  those  not  enlarged  in  length  or 
thickness,  and  showing  no  evidences  of  chronic  in- 
flammatory processes.  Such  tonsils  should,  ac- 
cording to  my  experience,  never  be  removed  by 
operation,  neither  on  account  of  the  effect  upon 
the  general  health,  nor  of  the  functional  activity 
of  the  organ  itself.  Even  though  the  physiologi- 
cal significance  of  the  tonsil  still  rests  upon  a  hy- 
pothesis, this,  like  any  other  healthy  organ  in  the 
body,  should  be  left  undisturbed." 

Mme.  Schumann-Heink:  "Yes." 

Mme.  Luisa  Tetrazzini:  "Yes." 

Miss  Cecelia  Winter:  "Yes." 

Arthur  J.  Hubbard:  "They  are." 

Mine.  Alice  Garrigue  Mott:  "In  some  cases. 
They  preserve  the  original  structure  of  the  throat 
on  which  depends  the  beauty  of  the  individual 
voice." 

Mme.  Cappiani:  "Certainly,  they  are  neces- 
sary for  the  acoustics  of  the  voice,  the  sounding 
board  of  which  is  in  the  nasal  bridge  where  from 
all  the  facial  bones  connected  with  each  other  are 


244  THE    TONSILS    AND    THE    VOICE 

awakened  to  resound  to — which  by  their  different 
shapes  give  different  tones,  forming  a  kind  of 
accord  to  the  one  tone  we  produce.  These  vibra- 
tions together  beautify  the  voice  in  sympathy  and 
grandeur  and  give  the  individual  ^'timbre  de  la 
voix." 

Lamperti:  "Most  decidedly,  I  consider  them 
of  the  greatest  importance  to  all  singers." 

Letter  of  Van  Baggen. 

Question  1.  Have  the  normal  faucial  tonsils 
any  function:  physiologic,  biologic,  chemical, 
phonetic,  or  other?  By  normal  faucial  tonsils,  I 
mean  the  tonsils  situated  in  the  fauces,  between 
the  anterior  and  posterior  palatine  arches,  in 
healthy  condition  and  of  such  size  as  not  to  pro- 
ject beyond  the  line  of  the  palatine  arches  nor 
press  upon  surrounding  tissues,  of  a  size  so  small 
as  not  to  interfere  with  the  perfect  anatomical 
outlines  of  the  walls  of  the  pharynx. 

Answer.  The  faucial  tonsils  have  certainly  a 
phonetic  function.  Their  situation  in  the  mouth 
at  a  place  where  the  voice  receives  an  essential 
part  of  its  specific  qualities  allows  us  to  admit 
this  assertion.  The  muscles  of  the  anterior  and 
posterior  pillars  of  the  fauces  between  which  the 
tonsils  rest,  are  in  constant  movement  when  we 
are  speaking  or  singing.  Their  action  combined 
with  the  movements  of  the  muscles  of  the  soft 
palate  changes  the  shape  of  the  voice  passage  at 
the  back  of  the  mouth  when  we  are  forming 
the  diff*erent  vocals  or  producing  tones  of  dif- 
ferent pitch.  The  position  of  the  tonsils  situated 
as  they  are  between  the  pillars  of  the  fauces  are 


SIX   VOICE    QUESTIONS  245 

of  great  importance  with  regard  to  the  enacti- 
tude  and  perf ectness  of  those  movements !  Also 
for  the  resonance  the  tonsils  are  of  great  interest 
for  the  voice.  With  their  spongy  tissue  they  can 
be  compared  to  the  felt  in  the  piano  which  softens 
the  tones  and  regulates  the  resonance. 

Question  2.  What  are  the  functions  of  the  fau- 
cial  tonsils? 

Answer.  For  my  answer  to  this  question,  see 
the  first  answer. 

Question  3.  What  effects  have  you  observed 
as  being  directly  due  to  removal  of  the  faucial 
tonsils  ? 

Answer.  Only  in  two  cases  during  my  expe- 
rience of  eight  years  the  removal  of  the  faucial 
tonsils  was  necessary.  In  both  cases  the  tonsils 
were  of  abnormal  size.  In  one  of  those  two  cases 
there  was  no  regular  movement  of  the  soft  pal- 
ate and  of  the  pillars  of  the  fauces;  especially 
when  forming  the  initial  vocals,  a  spasmodic  con- 
traction of  those  parts  took  place,  whereby  the 
swollen  tonsils  were  strongly  protruded.  Every 
attempt  to  correct  the  action  of  the  muscles  of  the 
soft  palate  and  the  pillars  of  the  fauces  remained 
without  any  result  because  of  this  projection  of 
the  tonsils.  After  their  removal  the  desired  effect 
was  obtained  by  carefully  applied  exercises. 

Question  4.  Have  you  noted  phonetic  changes 
after  removal  of  the  faucial  tonsils  ? 

Answer.  The  other  case  where  the  tonsils  were 
removed,  was  a  singer.  There  also  the  removal 
of  the  swollen  tonsils  appeared  unavoidable  be- 
cause of  the  impossibility  to  correct  a  nervous 
contraction  of  the  pillars  of  the  fauces.     As  a 


246  THE    TONSILS    AND    THE    VOICE 

result  of  the  removal,  entire  success  followed. 
It  did  not  affect  the  timbre  of  the  voice;  an  in- 
crease of  resonance  was  observed  and  she  sang 
with  far  more  ease  and  less  fatigue. 

Question  5.    Would  you,  as  a  rule,  advise  the 
removal  of  normal  tonsils? 
Answer.   No! 

Remarks.  As  I  am  exclusively  a  specialist- 
expert  for  voice  and  speech  afflictions  I  consid- 
ered the  questions  but  from  the  phonetic  point  of 
view. 

N.  J.  Poock  Van  Baggen, 
Plaats  10a, 

The  Hague, 
Holland. 

Addenda  to  Question  Number  One. 

Frank  E.  Miller:  "They  are  regulators  of  pil- 
lar action." 

Moure:  "They  have  phonetic  functions. 
From  a  phonetic  point  of  view,  their  normal 
role  must  evidently  be  to  prevent  in  a  certain 
measure  the  nasality  of  tone,  by  maintaining  the 
pillars  in  the  midst  of  which  they  are  placed." 

Van  Baggen:  "The  faucial  tonsils  have  cer- 
tainly a  phonetic  function.  Their  situation  in 
the  mouth  at  a  place  where  the  voice  receives  an 
essential  part  of  its  specific  qualities  allows  us  to 
admit  this  assertion.  The  muscles  of  the  ante- 
rior and  posterior  pillars  of  the  fauces,  between 
which  the  tonsils  rest,  are  in  constant  movement 
when  we  are  speaking  or  singing.  Their  action 
combined  with  the  movements  of  the  muscles  of 


SIX  VOICE   QUESTIONS  247 

the  soft  palate  changes  the  shape  of  the  voice 
passage  at  the  back  of  the  mouth  when  we  are 
forming  the  different  vocals  or  producing  tones 
of  different  pitch.  The  position  of  the  tonsils, 
situated  as  they  are  between  the  pillars  of  the 
fauces,  are  of  great  importance  with  regard  to 
the  exactitude  and  perfectness  of  those  move- 
ments. Also  for  the  resonance  the  tonsils  are  of 
great  interest  for  the  voice.  With  their  spongy 
tissue  they  can  be  compared  to  the  felt  in  the 
piano  which  softens  the  tone  and  regulates  the 
resonance." 


248  THE    TONSILS    AND    THE    VOICE 

Question  Xumber  Two. 

How,  or  in  what  manner,  are  normal  tonsils  of 
use  to  singers? 

Vincenzo  Sabatini:  "I  do  not  know." 

George  A.  Sweet:  "Of  no  use." 

David  Bispham:  "I  do  not  know,  and  do  not 
think  a  singer  should  consider  his  physical  for- 
mation at  all,  if  it  is  healthy,  and  as  little  as  pos- 
sible j,  if  it  is  (or  he  thinks  it  is)  sick." 

Richard  Loewenberg:  "Same  answer  as  to 
question  number  one." 

Frederick  E.  Bristol:  "The  answer  to  question 
number  one  is  mj^  answer  to  this  question." 

George  Fergusson:  "I  do  not  think  the  state- 
ment of  an  early  teacher  of  mine — an  Italian 
tenor — to  the  effect  that  the  tonsils  lent  brilliancy 
to  the  tone,  is  of  any  value  whatever." 

Mme.  Lillian  Nordica:  "I  have  never  been 
conscious  of  possessing  tonsils — so  know  of  no 
use — but  presume  they  are  there  for  a  purpose." 

Mme.  Irene  San  Carola:  "I  consider  that  they 
are  of  no  special  use  to  singers  as  such,  though 
doubtless  they  are  factors  both  in  pharyngeal 
and  general  health,  or  they  would  not  be  there." 

Charles  A.  White:  "Who  knows?" 

Carlo  Sebastiani:  "As  I  have  said,  the  utility 
of  the  normal  tonsils  in  singers  has  not  been 
proved  or  demonstrated,  as  to  what  might  be 
their  special  function  in  the  emission  of  the  voice. 
I  have  been  able  to  verify  that  the  larger  the 
development  of  the  tonsils,  the  more  difficult  is 
the  resonance  and  the  emission  of  the  tones  of  the 
second  register  or  high  notes:  even  the  removal 


SIX   VOICE    QUESTIONS  249 

of  the  normal  tonsils  does  not  facilitate  these  high 
tones." 

Mme.  Luisa  Tetrazzini:  "They  protect  the  vo- 
cal cords  from  dust,  microbes,  etc.,  also  being 
part  of  a  normal  throat  cannot  be  removed  with- 
out doing  injury." 

Mme.  Schumann-Heink:  "They  guard  the 
throat,  supply  fluid  secretion,  are  a  link  in  the 
chain.  They  were  put  there  by  nature.  We 
can  get  along  with  one  leg,  one  eye,  etc.,  but  we 
can  get  along  better  with  two." 

S.  S.  Curry:  "I  cannot  see  any  use  except  as 
they  affect  the  overtones  of  the  voice;  all  the 
chambers  of  the  pharynx  and  of  the  head,  and 
even  the  whole  body  affect  the  resonance  of  the 
voice.  When  the  tonsils  are  abnormal,  they  af- 
fect it  slightly  in  this  way." 

Mme.  Clara  Kathleen  Rogers:  "Only  as  fac- 
tors in  forming  the  perfect  resonator." 

Miss  Cecelia  Winter:  "In  healthy  condition, 
they  round  out  what  would  otherwise  be  an  irreg- 
ular cavity  without  power  of  adding  resonance. 
Since  the  fauces  are  not  firm  enough  in  material 
to  be  of  any  use  as  added  resonators  and  from  the 
standpoint  of  tone-quality  any  distortion  of  the 
air  wave  in  passing  them  would  be  more  detri- 
mental than  advantageous.  It  is  considered  well 
to  have  a  diseased  tonsil  that  protrudes  removed 
for  the  same  reason." 

Mme.  Alice  Garrigue  Mott:  "The  normal  fau- 
cial  tonsils  are  of  use  to  the  singer,  in  so  far  as 
they  preserve  the  original  structure  of  the  throat, 
on  which  depends  the  beauty  of  the  individual 
voice." 


250  THE   TONSILS   AND   THE   VOICE 

Arthur  J.  Hubbard:  "We  are  not  sure  how, 
but  we  know  that  their  removal  causes  a  difficulty 
in  assuming  different  shapes  of  the  pharynx 
necessary  in  singing,  causing  a  hardness  of  qual- 
ity and  laborious  action." 

Mme.  Cappiani:  "Already  described.  If  ton- 
sils are  cut  out  it  wants  considerable  skill  to  bring 
the  vibrations  of  whatever  tone  up  in  the  nasal 
bridge,  as  they  come  too  easily  from  the  larynx 
through  the  mouth  to  the  listener  in  a  harsh  or 
vulgar  tone,  without  that  sympathy  above  de- 
scribed when  all  the  facial  bones  are  awakened  to 
resonance." 

Lamperti:  "The  tonsils  are  most  necessary  for 
modulation  in  singing:  without  them  it  is  very 
difficult,  sometimes  impossible,  for  the  voice  to 
modulate.  They  assist  in  expanding  and  in 
withdrawing  the  tones." 


SIX   VOICE   QUESTIONS  251 

Question  Number  Three. 

Do  you  personally  know  of  any  instance,  or 
instances,  in  which  a  singer's  voice  was  improved 
after  removal  of  normal  tonsils? 

Mme.  Olive  Fremstad:  "Yes." 

Jean  de  Reszke:  "I  only  know  of  one  case 
among  my  pupils  of  the  tonsils  having  been  re- 
moved. The  operation  was  most  successfully 
performed,  and  the  result  excellent.  The  pupil's 
voice  is  now  better  than  ever  and  she  no  longer 
suffers  from  sore  throat,  as  she  did  before  the 
operation." 

Van  Baggen:  "Only  in  two  cases  during  my 
experience  of  eight  years,  the  removal  of  the 
faucial  tonsils  was  necessary.  In  both  cases,  the 
tonsils  were  of  abnormal  size.  In  one  of  these 
two  cases,  there  was  no  regular  movement  of  the 
soft  palate,  and  of  the  pillars  of  the  fauces;  es- 
pecially when  forming  the  initial  vocals  a  spas- 
modic contraction  of  those  places  took  place, 
whereby  the  swollen  tonsils  were  strongly  pro- 
truded. Every  attempt  to  correct  the  action  of 
the  muscles  of  the  soft  palate  and  the  pillars  of 
the  fauces  remained  without  any  results  because 
of  this  projection  of  the  tonsils.  After  their  re- 
moval the  desired  effect  was  obtained  by  care- 
fully applied  exercises." 

Carlo  Sehastiani:  "I  have  been  able  to  verify 
that  some  time  after  the  excision  of  the  tonsils, 
the  voice  has  improved,  the  resonance  facilitated 
and  the  color  of  the  voice  also  improved.  I  here 
speak  of  tonsils,  not  normal  but  of  tonsils  hyper- 
trophic diwd  hyperplastic.     In  this  case  the  ex- 


252  THE    TONSILS    AND    THE    VOICE 

cision  has  been  of  some  good,  because  they  were 
an  impediment  to  the  normal  function  of  the  soft 
palate." 

Charles  A.  White:  "Never  heard  of  the  re- 
moval of  tonsils  except  for  the  reason  that  thej^ 
were  abnormally  large  or  diseased." 

S.  S.  Curry:  "I  have  never  to  my  knowledge 
taught  a  case  that  had  the  normal  tonsils  re- 
moved. When  abnormal  tonsils  have  been  re- 
moved, there  is  a  slight  improvement  in  reso- 
nance." 

Charles  A.  Rice:  "No.  To  remove  any  part 
or  portion  of  a  normal  tonsil  is  unnecessarj'-  and 
will  in  no  way  aid  the  singer's  voice  in  tone  pro- 
duction or  in  quality." 

Mme.  Irene  San  Carola:  "No.  And  even 
when  tonsils  are  abnormally  large,  I  always  op- 
pose any  proposal  to  remove  them  by  surgery. 
I  prefer  to  try  every  other  means  of  reducing 
them  and  I  have  had  considerable  success  in  my 
methods." 

31  me.  Alice  Gairigue  Mott:  "I  know  no  case 
in  which  the  singer's  voice  was  improved  by  the 
removal  of  normal  tonsils." 

Mme.  Lillian  Nordica:  "I  do  not.  If  any  of 
ni}'^  comrades  have  had  their  normal  tonsils  taken 
out,  I  have  never  heard  of  it." 

Sir  Charles  Santley:  "I  do  not  know  of  any 
instance  of  improvement  or  injury  to  a  singer's 
voice  after  removal  of  the  tonsils." 

Frederick  E.  Bristol:  "Have  never  seen  any 
singer  w^hose  normal  tonsils  have  been  removed, 
so  far  as  I  know." 

Mme.  Clara  Kathleen  Rogers:  "I  have  never 


SIX    VOICE    QUESTIONS  253 

known  of  the  removal  of  normal  tonsils  from  the 
throat  of  a  singer." 

George  A.  Sweet:  "No." 

Mme.  Schumann-Heink:  "No.  Decidedly 
no." 

M7iie.  Luisa  Tetrazzini:  "No." 

David  Bispham:  "No." 

Bond:  "I  do  not." 

Stephen  Townsend:  "No." 

David  C.  Taylor:  "No." 

Miss  Cecelia  Winter:  ''^o^ 

Arthur  J.  Hubbard:  "No.  On  the  contrary, 
a  deterioration  in  quality  of  voice  and  of  ease  in 
singing." 

Richard  Loewenberg:  "I  do  not  know  of  any 
case  in  which  a  singer's  voice  was  improved  by 
the  removal  of  normal  tonsils.  On  the  contrary," 

M7ne.  Cappiani:  "No!  But  the  voice  may  be 
changed  to  higher  or  lower  pitch  by  the  cicatriza- 
tion, what  the  chirurgeon  cannot  know  before- 
hand, which  way  the  result  will  be.  Often  the 
compass  of  the  voice  may  not  be  changed  at  all; 
only  the  sounding  quality  becomes  more  ordi- 
nary." 

Laniperti:  ''No.  If  the  tonsils  are  normal^ 
they  should  on  no  account  be  removed, 
as  the  removal  will  never  improve  the  voice. 
If  abnormal,  only  the  projecting  part  should 
be  most  carefully  removed,  never  the  whole 
tonsil  taken  out,  but  merely  the  diseased 
part  cut  off.  /  am  decidedly  op  loosed  to  the 
growing  tendency  of  having  tonsils  cut  and  re- 
moved" 


254  'J^HE    TONSILS    AND    THE    VOICE 

LETTER  OF  DR.  LOEWENBERG. 

Translation. 

Berlin  W., 
62  Keith  Street,  22nd  March,  1912. 
Richard  B.  Faulkner,  M.D., 

306  Diamond  Bank  Building,  Pittsburgh,  Pa. 

My  dear  Doctor: — I  received  your  short  let- 
ter of  January  9th,  and  thank  you  for  your 
expression  of  confidence  in  my  opinion  con- 
cerning the  questions  under  consideration,  and 
gladly  express  my  opinion  as  follows: 

(1)  In  the  first  place,  to  prevent  misunder- 
standing, by  "normal"  tonsils,  I  mean  tonsils  of 
a  healthy  color,  those  not  enlarged  in  length  or 
thickness,  and  showing  no  evidences  of  chronic 
inflammatory  processes.  Such  tonsils  should, 
according  to  my  experience,  never  be  removed 
by  operation,  neither  on  account  of  the  effect 
upon  the  general  health,  nor  of  the  functional 
activity  of  the  organ  itself.  Even  though  the 
physiological  significance  of  the  tonsil  still  rests 
upon  a  hypothesis,  these,  like  any  other  healthy 
organ  in  the  body,  should  be  left  undisturbed. 

(2)  These  remarks  will  also  answer  question 
Number  1. 

(3)  I  do  not  know  of  any  case  in  which  a 
singer's  voice  was  improved  on  the  removal  of 
normal  tonsils. 

(4)  On  the  contrary,  I  know  of  cases  in  which 
the  removal  of  normal  tonsils  has  caused  perma- 
nent detrimental  effects  to  the  voice,  in  conse- 


SIX   VOICE    QUESTIONS  255 

quence  of  the  unavoidable  injury  to  the  arches  of 
the  palate  ( adhesions,  scar  tissue,  etc. ) . 

(5)   For  these  reasons,  I  disapprove  of  opera- 
tion upon  normal  tonsils  in  all  cases. 
I  am  always  glad  to  be  of  service. 

Sincerely, 
(Signed)  Dr.  Richard  Loewenberg. 


256  THE    TONSILS    AND    THE    VOICE 

Question  Number  Four. 

Do  you  personally  know  of  any  instance,  or 
instances,  in  which  a  singer's  voice  was  impaired 
or  mined,  after  the  removal  of  normal  tonsils  ? 

Richard  Loewenherg:  "I  know  of  cases  in 
which  the  removal  of  normal  tonsils  has  caused 
permanent  detrimental  effects  to  the  voice,  in 
consequence  of  the  unavoidable  injury  to  the 
arches  of  the  palate  (adhesions,  scar  tissue,  etc.) ." 

David  Bispham :  "Most  persons  have  constant 
trouble  after  such  an  operation,  and  though  their 
voices  are  not  "ruined"  the  healthy  operation  of 
the  parts  that  contribute  to  good  singing  is  inter- 
fered with." 

Mme.  Alice  Garrigue  Mott:  "I  recall  no  case 
where  a  singer's  voice  was  ruined  after  removal 
of  the  tonsils.  I  know  many  cases  where  the  re- 
moval of  tonsils  has  made  a  change  for  the  worse 
in  qualitj^" 

Mme.  Katherine  E.  von  Klenner:  "Yes; 
many." 

Mme.  S chumann-H eink :  "I  know  of  several. 
The  voice  became  acid,  uncertain,  weak  or  rough, 
or  was  entirety  ruined." 

Carlo  Sehastiani:  "Often  the  voice  has  been 
damaged  if  the  operation  on  the  tonsils  was  not 
necessary,  but  simply  performed  for  the  desire 
to  increase  or  to  improve  the  voice,  as  it  has  been 
practiced  by  some  artists  whom  to  deficienc}^  of 
vocal  faculties  and  the  mediocrity  of  talent,  they 
want  to  substitute  the  surgical  instruments.  In 
similar  cases,  the  voice  has  been  damaged  and 
sometimes  entirely  lost: 


SIX    VOICE    QUESTIONS  257 

"(1)  Because  the  too  frequent  use  and  not 
enough  justified  to  alter  with  surgical  instru- 
ments so  delicate  an  organ  as  that  of  the  voice, 
it  is  not  well  for  the  clearness,  the  exercise,  the 
color  and  facility  of  the  voice; 

"(2)  Because  the  tissues,  the  nerves,  the 
muscles,  always  remain  depreciated  from  an 
operation  that  was  not  compulsory  to  avoid 
greater  damages." 

31  me.  Luisa  Cappiani:  "A  singer's  voice  can- 
not be  entirely  ruined  by  cutting  out  the  tonsils. 
It  is  too  great  a  distance  from  tonsils  to  the  vocal 
bands  in  the  larynx." 

Mine.  Marie  L.  Everett:  "I  am  fully  pre- 
pared to  say — indeed,  am  convinced — that  with 
the  removal  of  the  tonsils,  the  voice  loses  much 
of  its  personal  quality;  and  much  of  its  frontal 
focus — or  in  other  words — somethi7ig  is  missed  in 
the  quality  after  the  tonsils  have  been  removed 
that  does  not  come  back.  The  tone  seems  dis- 
persed— not  as  well  forward — and  lacks  its  usual 
brilliancy  of  resonance." 

Arthur  J.  Hubbard:  "Not  ruined,  but  im- 
paired." 

David  C.  Taylor:  "I  know  of  two  instances, 
neither  one  of  which  was  my  pupil,  of  voice  im- 
pairment following  some  months  after  the  re- 
moval of  tonsils  which  I  was  informed,  were  nor- 
mal. But  I  cannot  state  that  this  impairment 
was  due  to  the  removal  of  the  tonsils,  as  several 
other  causes  might  have  operated." 

Mine.  Irene  San  Carola:  "No,  not  personally 
— though  I  have  heard  of  such  instances — and 
such  mutilations  would,  prima  facie^  appear  to 

18 


258  THE    TONSILS    AND    THE    VOICE 

me  as  not  only  useless  but  likely  to  limit  poten- 
tialities." 

Charles  A.  White:  "Normal,  no.  Abnormal, 
yes — improved. ' ' 

Charles  A.  Rice:  "I  have  known  of  cases 
where  loss  of  voice  had  been  attributed  to  the  re- 
moval of  the  tonsils,  and  the  conditions  appeared 
to  verify  the  conclusion,  but  in  several  instances 
where  I  have  had  the  opportunity  of  working 
with  the  voice  after  it  had  been  pronoimced 
ruined,  it  has  developed  that  the  trouble  came  not 
from  the  removal  of  the  tonsils,  but  from  the 
teachers'  lack  of  knowledge  in  vocal  physiology 
and  tone  production.  The  pain  and  imaginary 
troubles  of  the  singer's  tonsils  are  invariably  due 
to  wrong  tone  production  (i.e.:  placement  of  the 
voice).  This  I  have  proved  many  times  with 
students  who  came  to  me  with  the  impression  that 
their  tonsils  would  have  to  be  removed,  but  after 
a  few  weeks'  study  all  the  throat  trouble  had  dis- 
appeared without  an  operation." 

Mme.  Lillian  Nordica:  "I  do  not.  And  I  have 
never  heard  of  removing  normal  tonsils  any 
more  than  removing  a  normal  vocal  cord." 

Bonci:  "I  do  not." 

3Iiss  Cecelia  Winter:  "I  know  of  no  singer 
who  ever  had  a  normal  tonsil  removed." 

Sahatini:  "Same  answer  as  Number  3." 

Mme.  Clara  Kathleen  Rogers:  "No." 

Mme.  Olive  Fremstad:  "No." 

George  A.  Sweet:  "No." 

Stephen  Townsend:  "No." 

S.  S.  Curry:  "No." 

Frederick  E.  Bristol:  "No." 


SIX   VOICE   QUESTIONS  259 

Question  Number  Five. 

Would  you,  as  a  rule,  advise  the  removal  of 
normal  tonsils  in  singers? 

Lamperti:  "Most  decidedly  not;  as  long  as 
they  are  normal,  they  are  far  too  necessary  in 
singing  and  only  when  greatly  enlarged  should 
the  diseased  part  be  removed,  never  the  entire 
tonsil." 

Richard  Loewenherg:  "I  disapprove  of  opera- 
tion upon  normal  tonsils  in  all  cases." 

Mme.  Lilli  Lehinann:  "No.  I  never  would 
advise  the  removal  of  anything  from  the  throat 
(of  a  singer)." 

Jean  de  Reszke:  "I  do  not  believe  in  removing 
the  tonsils  unless  they  are  abnormally  developed, 
but  certainly  would  recommend  the  operation 
being  performed  in  any  case  where  a  singer  is 
troubled  by  unusually  large  tonsils." 

Sir  Charles  Santley:  "Certainly,  I  would  not 
advise  the  removal  of  the  tonsils  under  any  ordi- 
nary circumstances,  but  attack  the  root  of  the 
evil,  the  ill-treated  stomach." 

Carlo  Sehastiani:  "No;  unless  the  operation 
has  been  deemed  necessary  in  the  opinion  of  the 
physician,  to  avoid  grave  misery  and  special 
pathological  cases.  These  cases  must  be  sepa- 
rately studied  in  each  individual  by  the  physi- 
cian." 

Mme.  Cappiani:  "No.  Only  in  cases  of  dis- 
eased and  such  swollen  tonsils  that  danger  of 
suffocation  is  near,  then  they  must  be  cut  out,  as 
it  is  better  to  lose  one's  tonsils  than  one's  life." 

George  A.  Sweet:  "No,  I  have  never  advo- 


260  THE    TONSILS    AND    THE    VOICE 

cated  the  removal  of  a  singer's  tonsils,  except  in 
extreme  cases,  when  chronically  enlarged  from 
colds  covering  periods  of  many  years — or  result- 
ing from  organic  disease   (scrofula)." 

Charles  A.  Bice:  "Never.  The  removal  of 
the  normal  tonsils  is  an  unnecessary  operation 
and  accomplishes  nothing ;  therefore,  I  would  not 
sanction  such  an  operation." 

Stephen  Townsend:  "No." 

George  Fergusson:  "I  have  had  no  experience 
with  singers  who  have  had  the  normal  tonsils  re- 
moved. Personally  I  am  opposed  to  their  re- 
moval in  a  normal  state." 

Arthur  J.  Hubbard:  "No,  most  decidedly. 
During  twenty  odd  years  of  experience,  I  have 
encountered  many  cases  of  diseased  and  trouble- 
some tonsils.  My  conclusions  based  on  careful 
observation  of  the  treatment  given  them  are  that 
normal  tonsils  are  useful  and  should  never  be  re- 
moved. And  also,  when  diseased  ones  are  re- 
moved, as  should  always  be  done,  great  care 
should  be  exercised  not  to  cut  deeply.  In  fact  to 
leave  enough  to  constitute  what  would  be  gener- 
ally called  a  normal  tonsil.  In  many  cases 
among  my  pupils,  I  have  observed  nothing  but 
good  results  from  the  removal  of  diseased  ton- 
sils, when  done  in  the  manner  above  indicated. 
But  I  have  known  great  harm  to  be  done  when 
the  operation  has  extended  too  far." 

Mme.  Alice  Garrigue  Mott:  "I  never  advise 
removal  of  normal  tonsils." 

Mme.  Clara  Kathleen  Rogers:  "Certainly 
not." 

Mme.  Katherine  E.  Von  Klenner:  "No." 


SIX    VOICE    QUESTIONS  261 

Mme.  Lillian  Nordica:  "1  certainly  deprecate 
meddling  with  normal  organs.  I  have  never  had 
my  throat  touched,  or  sprayed,  in  my  life." 

Mine.  Luisa  Tetrazzini:  "Never." 

Mine.  Olive  Fremstad:  "No." 

Mm  Cecelia  Winter:  "No." 

Mine.  Irene  San  Carola:  "Certainly  not.  I 
consider  that  a  perfect  control  of  all  parts  of 
the  pharynx,  as  well  as  of  all  organs  engaged  in 
voice  production,  can  and  should  be  acquired 
through  exercise  for  the  development  of  the  par- 
ticular muscles  employed." 

Mme.  Marie  L.  Everett:  "I  thoroughly  be- 
lieve in  having  tonsils  removed  that  are  trouble- 
some. They  often  are  but  a  trap  for  disease. 
But  I  certainly  have  noticed  a  loss  in  the  person- 
ality, and  in  the  warmth  or  coloring  of  the  tone 
in  those  pupils  who  have  had  the  tonsils  removed 
during  the  period  of  study  with  me.  I  have  a 
case  I  am  studying  now — a  pupil  who  had  ton- 
sils removed  in  the  summer — tone  larger,  clear- 
er— hut  less  beauty — the  personal  charm  seems 
affected." 

Frederick  E.  Bristol:  "I  would  not — in  fact 
I  am  very  much  opposed  to  any  surgery  in  con- 
nection with  the  throat  and  nose,  except  in  cases 
where  the  tonsils  have  grown  to  an  abnormal 
size,  or  where  there  are  growths  on  the  vocal 
cords  which  cannot  be  removed  in  any  other  way. 
I  have  known  of  two  instances  where  enlarged 
tonsils  were  removed  to  the  great  injury  of  the 
voice,  and  I  have  had  several  cases  come  under  my 
observation  where  benefit  accrued  by  their  remov- 
al. I  have  always  attributed  the  former  cases  to  a 


262  THE    TONSILS    AND    THE    VOICE 

bungling  operation.  I  am  drifting  farther  and 
farther  away  from  resorting  to  surgery,  and 
have  been  pleased  to  note  that  in  very  many  cases 
the  cure  of  any  trouble  has  been  effected  through 
a  normal  use  of  the  voice,  produced  upon  a  cor- 
rect method.  Please  observe  that  I  do  not  say 
there  may  not  be  need  in  some  cases  of  surgery." 

A.  Bond:  "No,  unless  there  is  some  special 
reason." 

David  Bispham:  "Certainly  not!!" 

Vincenzo  Sahatini:  "No." 

S.  S.  Curry:  "I  can  see  no  reason  for  the  re- 
moval of  normal  tonsils." 

David  C.  Taylor:  "Not  under  any  condi- 
tions." 

Charles  A.  White:  "Never." 

LETTER  OF  SEBASTIANI. 

Translation. 

Richard  B.  Faulkner,  M.D.    (Columbia), 
306  Diamond  Bank  Building, 
Pittsburgh,  Pa. 

Answer  to  Question  No.  1.  Anything  belong- 
ing to  our  organism  has  its  function  and  its 
proper  reason  to  exist.  Only  the  excess  or  the 
deficiency  of  any  part  whatsoever  can  be  of  detri- 
ment to  the  organism.  As  to  the  first  part  of 
this  question,  the  normal  tonsils,  they  might,  per- 
haps, be  of  utility  to  the  voice,  to  modify  the 
resonance  and  the  timbre.  Though  it  is  not 
proven  by  me. 

Answer  to  Question  No.  2.  As  I  aforesaid, 


SIX    VOICE   QUESTIONS  263 

the  utility  of  the  normal  tonsils  in  singers  is 
not  proven  or  demonstrated,  or  what  might  be 
their  special  function  in  the  emission  of  the  voice. 
I  have  been  able  to  verify  that  the  larger  the  de- 
velopment of  the  tonsils,  the  more  difficult  is  the 
resonance  and  the  emission  of  the  tones  of  the 
second  register  or  high  tones:  even  the  removal 
of  the  normal  tonsils  does  not  facilitate  these 
high  tones. 

Answer  to  Question  No.  3.  I  have  been  able 
to  certify  that  some  time  after  the  excision  of 
the  tonsils,  the  voice  has  improved,  the  resonance 
facilitated  and  the  color  of  the  voice  also  im- 
proved. I  here  speak  of  tonsils,  not  normal,  but 
of  tonsils  hypertrophic  and  hyperplastic.  In 
this  case,  the  excision  of  the  tonsils  has  been  of 
some  good,  because  they  were  an  impediment  to 
the  normal  function  of  the  soft  palate. 

Answer  to  Question  No.  4.  Often  the  voice 
has  been  damaged  if  the  operation  on  the  tonsils 
was  not  necessary,  but  simply  performed  with  the 
desire  to  increase  or  to  improve  the  voice,  as  has 
been  practiced  by  some  artists,  when,  for  deficien- 
cy of  vocal  faculties  and  the  mediocrity  of  talent, 
they  wished  to  substitute  the  surgical  instrument. 
In  similar  cases,  the  voice  has  been  damaged  and 
sometimes  entirely  lost: 

(1)  Because  the  too  frequent  use  and  not 
enough  justified  to  alter  with  surgical  instru- 
ments so  delicate  an  organ  as  that  of  the  voice,  it 
is  not  well  for  the  clearness,  the  exercise,  the 
color  and  facility  of  the  voice ; 

(2)  Because  the  tissues,  the  nerves,  the  mus- 
cles, always  remain  depreciated  from  an  opera- 


264  THE    TONSILS    AND    THE    VOICE 

tion  that  was  not  compulsory  to  avoid  greater 
damage. 

Answer  to  Question  No.  5.  No,  unless  the 
operation  has  been  deemed  necessary  in  the  opin- 
ion of  the  physician,  to  avoid  grave  misery  and 
special  pathological  conditions.  These  questions 
must  be  separately  studied  in  each  individual  by 
the  phj^sician. 

Remarks:  (1)  The  function  of  the  tonsils  is 
not  known. 

(2)  The  benefit  that  may  be  derived  by  the 
excision  of  the  tonsils,  if  it  is  of  great  utilitj^  in 
cases  of  hypertrophy,  to  avoid  greater  damage, 
it  may  be  of  some  benefit  to  the  human  voice  in 
general:  it  may  not  be  of  any  benefit  to  special- 
ized organisms  endowed  with  exceptional  and 
valuable  voices,  said  voices  being  of  great  value 
precisely  for  the  virtue  of  the  mucosa  tissues; 
for  the  softness  of  the  muscles  and  nerves;  for 
the  perfection  of  the  different  cavities  of  reson- 
ance; finally,  for  the  marvelous  structure  of  the 
entire  vocal  apparatus. 

Then 

In  these  uncommon  conditions,  an}''  surgical 
operation  whatsoever,  it  matters  not  how  perfect, 
may  cause  harm  to  the  precious  instrument. 

(Signed)    Caelo  Sebastiani. 

Napoli,  March  31,  1910. 


SIX   VOICE   QUESTIONS  265 

Question  Number  Six. 
Remarks  ? 

William  Shakespeare:  "1  suspect  that  most 
swollen  tonsils  are  the  result  of  a  rigid  manner  of 
using  the  voice,  both  in  singing  and  in  speaking. 

My  own  pupils  have  no  difficulty  with  the  ton- 
sils, and  generally  I  am  looked  at  askance  by 
throat  specialists  as  a  kind  of  enemy,  which  I  am 
not.  Should  swollen  tonsils  arise  from,  say,  con- 
stitutional weakness,  I  feel  they  may  be  removed 
with  advantage.  A  skilful  surgeon  can  do  this 
without  cutting  into  the  adjacent  muscles,  but 
I  have  had  pupils  who  have  suffered  from  faulty 
operation." 

Vincenzo  Sabatini:  "Only  time  I  have  ever 
recommended  removal  of  the  tonsils  has  been  in 
cases  where  they  were  abnormal,  and  the  result 
has  always  been  a  marked  improvement  in  the 
voice.  But  when  normal,  the  best  advice  is  to 
leave  them  alone" 

Mme.  Clara  Kathleen  Rogers:  "My  observa- 
tions and  experience  lead  me  to  the  following 
conclusions:  In  a  healthy,  normal  throat  each 
part  has  its  proven  normal  function,  passive  or 
active,  direct  or  indirect:  That  the  emission  of 
vocal  sound,  given  a  musical  sense  and  impulse, 
follows  naturally  a  healthy  condition  of  the 
whole  throat  as  nature  made  it;  and  that  disease 
or  malformation  alone  warrants  the  removal  of 
the  tonsils,  just  as  the  intervention  of  surgery  is 
required  for  a  hare  lip  or  a  tied  tongue.'" 

Mme.  Irene  San  Carola:  "My  whole  scheme 


266  THE   TONSILS   AND   THE    VOICE 

of  instruction  is  opposed  to  any  avoidable  inter- 
ference with  nature,  being  based  on  the  convic- 
tion that  intelhgent  use  of  the  natural  means 
for  the  full  development  of  the  vocal  organs 
eventuates  in  an  ability  to  control  every  part  of 
the  machinery  of  voice  production." 

Mme.  Katherine  E.  von  Klenner:  *'I  make  a 
point  in  replying  to  your  questions  upon  the 
word  7iormal  in  each  case.  JMy  observations 
agree  with  those  of  my  teachers,  Manuel  Garcia 
and  Pauline  Viardot-Garcia,  both  of  whom  ob- 
jected seriously  to  any  artificial  means  for  im- 
proving the  singing  voice — where  the  vocal  ap- 
paratus was  normal.  When  removed,  I  have 
always  found  a  certain  lack  of  sweetness  in  the 
tone  quality — and  difficulty  in  supporting  the 
tone  in  certain  registers." 

Charles  A.  Rice:  "An  abnormal  tonsil  will 
disturb  or  impair  both  quality  and  tone  place- 
ment by  displacing  the  walls  of  the  pharynx, 
etc.  The  poor  tonsils  are  made  the  scapegoat 
for  almost  all  the  failures  of  the  vocal  student. 
When  there  is  a  failure  in  the  voice,  the  teachers 
blame  the  tonsils,  never  themselves. 

"As  to  singing,  the  normal  tonsils  give  the 
pupil  no  inconvenience ;  in  fact,  they  never  know 
that  they  have  such  a  thing  when  the  voice  is 
properly  placed.  In  proper  voice  placement  and 
tone  production,  the  tonsils  always  remain  nor- 
mal, but  nothing  will  enlarge  the  tonsils  as  quick- 
ly as  had  placement  of  the  voice.  Not  only  are 
the  tonsils  enlarged,  but  the  intrinsic  muscles  are 
often  impaired,  and  sometimes  this  extends  to 
a  paratysis  of  the  arytenoids.     Then  the  ton- 


SIX   VOICE   QUESTIONS  267 

sils  are  removed,  with  little  or  no  relief,  for  the 
trouble  has  not  been  with  the  tonsils,  but  caused 
by  strain  on  the  entire  vocal  apparatus. 

"After  studying  with  some  twenty  or  more 
vocal  teachers,  I  found  only  one  that  understood 
vocal  physiology  and  could  place  the  voice  from 
scientific  knowledge.  A  vocal  teacher  must  be 
more  than  a  person  that  has  studied  to  train  his 
own  voice.  Find  the  teacher  that  has  studied  to 
teach,  one  that  puts  himself  through  some  of  the 
studies  and  researches  that  a  physician  has  to 
go  through,  and  has  developed  and  made  a  suc- 
cess with  his  own  voice  (if  he  cannot  develop 
his  own  voice  in  tone  placement  and  quality,  he 
cannot  train  others) ,  and  you  are  likely  to  find  a 
vocal  teacher  or  trainer  of  the  voice." 

Sir  Charles  Santley:  "My  experience  is  that 
they  (the  tonsils)  contract  an  unhealthy  condi- 
tion through  'inattention  to  diet,'  an  error  to 
which  singers  as  a  rule  are  addicted.  If  people 
would  confine  themselves  to  what  is  good  for 
them  and  not  insist  upon  merely  pleasing  the 
palate,  neither  their  tonsils  nor  their  systems  in 
general  would  suffer  much." 

Stephen  Townsend:  "To  me  it  is  very  difficult 
to  conceive  of  any  one  having  a  normal  tonsil 
removed.  I  can  see  nothing  to  be  gained  by  such 
an  operation.  Just  what  the  use  is  of  the  ton- 
sils, its  function,  is,  I  believe,  a  mooted  question 
even  among  the  medical  profession. 

"There  is  every  reason  why  an  enlarged,  dis- 
eased tonsil  should  be  taken  out,  and  this  is  ap- 
preciated as  much  by  the  vocal  instructor  as  by 
the  medical  man.     It,  however,  requires  a  skil- 


268  THE  TONSILS    AND   THE    VOICE 

ful  operator  to  perform  this  operation,  as  a 
bungling  'job'  is  very  liable  to  more  or  less  im- 
pair the  voice,  at  least  for  a  longer  or  shorter 
period." 

Miss  Cecelia  Winter:  "It  is  a  vrell-known  fact 
amongst  singers  that  the  throats  that  have  not 
been  tampered  with  surgically  are  the  strongest 
and  least  apt  to  be  subject  to  indispositions  from 
the  weather,  etc." 

David  Bispham:  "Most  persons  have  constant 
trouble  after  removal  of  the  tonsils,  and  though 
their  voices  are  not  'ruined,'  the  healthy  opera- 
tion of  the  parts  that  contribute  to  good  singing 
is  interfered  with.  I  am  sure  the  'doctor  habit' 
is  bad  for  a  singer  and  his  throat,  and  that  the 
more  he  goes  to  throat  specialists,  the  worse  he 
becomes.  I  am  also  sure  that  the  vocal  cords 
should  never  be  touched  on  any  account ^  and  that 
the  application  of  acids  and  sprays  to  throat  and 
nose  only  tends  to  continue  any  irritation  that 
may  be  and  that  doctors  are  not  sufficiently  care- 
ful to  ascertain  the  personal  equations — as  it 
were — of  their  patients.  I  am  a  well  man  and 
singer  to-day  because  I  do  not  go  to  throat  spe- 
cialists any  longer!  Excuse  my  frankness — but 
you  want  my  opinion,  I  take  it." 

Mme.  Schumann-Heink:  "There  is  nothing  I 
am  more  violently  opposed  to  than  any  radical 
treatment  of  a  singer's  throat. 

More  voices  are  ruined  by  ignorant  throat  spe- 
cialists than  by  use.  Dry  powders,  scraping 
operations,  acids,  instead  of  rest,  massage  and 
oil,  do  the  greatest  damage  to  singers.  My  spe- 
cialist has  enabled  me  to  sing  oftentimes  when  I 


SIX   VOICE    QUESTIONS  269 

believed  there  was  not  a  note  in  my  throat,  by  ap- 
plications of  oil,  oil,  oil,  and  if  any  heroic  meas- 
ures were  necessary,  they  were  used  only  after  a 
coating  of  oil,  and  only  in  the  mildest  form.  A 
mild  electric  treatment  externally  on  the  chest 
and  neck  and  back  was  an  infrequent  treatment." 

Mme.  Lilli  Lehmann:  "No,  I  never  would  ad- 
vise the  removal  of  anything  from  the  throat  and 
would  always  try  to  cure  it  without  any  opera- 
tion. If  someone  is  troubled  with  something  in 
his  throat,  you  never  can  tell  the  cause  if  you 
don't  know  the  person  well  and  his  manner  of 
singing.  I  am  quite  sure  that  every  bad  stand- 
ard of  health  in  the  throat  can  be  cured  in  learn- 
ing how  to  use  properly  all  the  muscles.  But 
how  seldom  are  they  used!  Never  with  knowl- 
edge. Singers  who  sing  well,  as  they  should  do, 
will  never  be  troubled  by  anything.  We  do  not 
feel  the  f aucial  tonsils  nor  the  vocal  cords ;  we  can 
arrange  our  tones  with  all  our  organs,  to  make 
them  perfect,  quite  high  and  low  enough, 
strong  and  soft  at  once.  You  should  know  well 
both  the  person  and  his  manner  of  singing.  I 
can  only  say  that  I  in  my  whole  life  never  had  a 
suffering  pupil  because  they  sang  right.  I  am 
sure  that  every  organ,  vocal  organ,  or  muscle, 
etc.,  in  an  ill  way,  may  trouble  some  people. 
But  if  you  don't  know  how  they  speak  or  sing, 
you  never  can  be  sure  of  the  reason :  whether  the 
trouble  comes  from  false  usage  of  the  vocal  or- 
gans, or  whether  the  false  (bad)  singing  or  speak- 
ing comes  from  a  bad  condition  of  the  vocal 
organs." 

Mme.  Lillian  Nordica:  "One  should  so  sing  as 


270  THE    TONSILS    AND    THE    VOICE 

not  to  injure  one's  self.  Something  is  very 
wrong  when  after  singing  the  throat  or  nose  or 
lungs,  or  anj^  one  part  of  the  body,  suffers.  A 
general  fatigue  should  follow — such  as  a  few 
hours'  sleep  will  repair.  So  it  seems  to  me  I 
would  let  normal  organs  alone." 

Mme.  Cappiani:  "It  is  wrong  and  very  wrong 
to  have  the  tonsils  removed, 

"(1)  Tonsils  are  full  of  blood,  situated  in  the 
fauces  like  two  stoves  warming  the  outside  winter 
air,  before  it  reaches  the  bronchial  tubes  and 
lungs,  thus  preventing  bronchitis,  pulmonitis, 
etc.,  etc. 

"(2)  Tonsils  are  guardians  against  hard  sub- 
stances: they  close  instinctively,  like  the  eyes  do 
when  an  object  comes  near  them,  and  often  Mn- 
der  the  hard  substances  to  be  swallowed." 

Carlo  Sebastiani:  "(1)  The  fimction  of  the 
tonsils  is  not  known.  (2)  The  benefit  that  can 
be  derived  by  the  excision  of  the  tonsils,  if  it  is 
of  great  utility  in  cases  of  hypertrophy,  to  avoid 
greater  damages,  it  may  be  of  some  benefit  to  the 
human  voice  in  general;  it  may  not  be  of  any 
benefit  to  specialized  organisms  endowed  with 
exceptional  and  valuable  voices,  said  voices  being 
of  great  value  precisely  for  the  virtue  of  the 
mucosa  tissues;  for  the  softness  of  the  muscles 
and  nerves;  for  the  perfection  of  the  different 
cavities  of  resonance;  finally,  for  the  marvelous 
structure  of  all  the  vocal  conduct. 

'^'Then,  in  these  uncommon  conditions  any 
surgical  operation  whatsoever,  it  matters  not  how 
perfect,  can  cause  harm  to  the  precious  instru- 
ment." 


SIX    VOICE    QUESTIONS  271 

Lamperti:  "I  am  decidedly  opposed  to  the 
growing  tendency  of  having  tonsils  cut  and  re- 
moved. In  almost  all  cases  I  have  found — in 
the  fifty  years  of  my  teaching — that  the  voice  is 
injured,  often  beyond  remedy.  The  tonsils  are 
as  necessary  in  the  modulation  of  the  voice  as 
the  nostril  is  to  breathing ;  remove  the  latter,  and 
you  obstruct  the  passage  of  breathing,  remove 
the  former  and  you  prevent  the  voice  from  ex- 
panding in  a  crescendo  and  drawing  together 
again  for  a  diminuendo. 

"I  trust  I  have  made  myself  plain.  I  wish 
you  every  success  in  the  collection  of  material 
upon  so  important  a  subject  to  all  singers,  who 
unfortunately  are  only  too  ready  to  remove  ton- 
sils." 


CHAPTER  XI 
DIAGNOSIS. 

The  scientific  consideration  of  the  organ  neces- 
sarily rests  upon  a  clear  conception  of  what  con- 
stitutes a  normal  faucial  tonsil — a  scientific  defi- 
nition is  essential. 

The  scientific  treatment  of  diseases  of  the 
tonsil  depends  primarily  and  absolutely  upon  a 
correct  diagnosis.  A  faulty  diagnosis  vitiates 
therapeutic  success.  To  treat  without  a  diagno- 
sis is  a  clear  case  of  the  blind  leading  the  blind 
into  pitfalls.  He  who  fails  to  make  every  effort 
to  establish  an  accurate  diagnosis  is  unworthy  of 
scientific  consideration.  And  what  of  him  who 
attempts  to  minimize  its  value?  The  treatment 
of  any  disease,  of  any  organ,  without  a  diagnosis, 
is  a  hazardous  performance. 

SajouSj,  in  his  great  work  on  the  Internal  Se- 
cretions, declares  that  at  the  present  day  investi- 
gators do  not  avail  themselves  of  the  enormous 
array  of  solid  data  available  to  ascertain  the 
truth :  and  that  the  confusion  which  characterizes 
the  medicine  of  our  day  is  due  to  the  habit  of 
theorizing  with  a  few  facts  as  foundation. 

With  the  purpose  of  simplifying  diagnos'is, 
I  divide  diseases  of  the  tonsil  into  six  groups, 
namely : 

( 1 )  Primary. 

(2)  Secondary. 

(3)  Symptomatic. 

272 


DIAGNOSIS  273 

(4)  Reflex. 

(5)  Mechanical. 

(6)  Hyperplastic. 

Primary. 

Von  Levinstein  thinks  that  many  diseases  find 
their  entrance  to  the  organism  through  the  ton- 
sil, but  he  believes  that  the  infection  theory  of 
Winslow  is  too  extreme  when  it  considers  the  ton- 
sil as  a  menace  to  the  organism. 

We  are  not  entitled  to  talk  of  a  danger  to  the 
organism  from  this  organ. 

Von  Levinstein  admits  that  angina  follows 
coryza,  but  he  does  not  concede  that  it  is  always 
secondary  to  nasal  affection.  That  the  latter 
mode  of  infection  does  not  happen  rarely  Von 
Levinstein  has  conceded.  He  also  mentions  the 
well-known  angina  following  endonasal  opera- 
tion, called  by  Frdnhel  "angina  traumatica,"  in 
which  the  germs  are  transported  from  the  nose 
via  the  lymph  vessels  to  the  tonsil.  Von  Levin- 
stein emphasizes  that  primary  disease  of  the  ton- 
sils is  a  common  occurrence  and  that  the  prim- 
ary disease  of  the  lymphatic  apparatus  can  be 
observed  at  least  as  frequently  as  the  primary  dis- 
ease of  the  other  organs  of  the  throat. 

Von  Levinstein  states  that  he  has  sometimes 
been  able  t,o  prove  that  a  patient  first  suffers 
from  an  angina  which  is  followed  in  a  few  days 
by  an  acute  catarrh  in  the  nose,  so  that  in  these 
cases  angina  is  the  primary  disease.  The  pos- 
sibility of  primary  infection  of  the  faucial  tonsil 
is  conceded  by  the  advocates  of  the  protective 

19 


274  THE   TONSILS   AND   THE   VOICE 

theory  only  when  the  protective  mechanism  is 
disturbed. 

Schoenemann  states  that  the  ordinary  angin- 
ous  affection  of  the  tonsil  is  not  a  primary  dis- 
ease, but  is  always  secondary  to  catarrh  of  the 
nasal  mucous  membrane. 

Goerke  considers  primary  disease  of  the  tonsil 
possible  only  when  the  protective  mechanism  is 
disturbed,  either  through  a  direct  injury  or 
through  a  cold,  and  that  the  organ  rarely  becomes 
a  victim  of  primary  infection. 

If  the  tonsil  is  in  a  state  of  acute  infection,  we 
should  consider  whether  the  disease  is  local  or 
general. 

The  observation  of  Stokr  that  the  epithelium 
of  the  tonsil  sometimes  represents  an  open 
wound,  thus  making  it  easy  for  micro-organisms 
to  here  enter  into  the  organism,  has  been  well 
refuted  by  Frdnhel  and  Jacohi. 

The  observation  of  Stohr  sometimes  spoken  of 
as  Stohr's  phenomenon,  is  seen  especially  in  the 
fossula  tonsillaris.  Everywhere  in  the  fossula 
white  blood  corpuscles  are  seen  passing  through 
the  ej^ithelium.  The  immigration  at  certain 
places  is  so  strong  that  it  is  difficult  to  find  the 
epithelium. 

If  we  assume,  as  Frdnhel  states,  that  the  lym- 
phatic current  simply  takes  along  the  lym- 
phocytes like  the  river  carries  logs,  we  have  to  omit 
the  idea  that  we  have  to  consider  here  an  open 
wound  but  that  we  have  to  learn  to  consider  it 
a  protective  mechanism,  for  the  micro-organisms 
would  have  to  swim  against  the  current  and  meet 
cells  which  possess  a  certain  phagocytosis. 


DIAGNOSIS  275 

If,  as  Frdnhel  states,  in  the  immigration  of 
white  corpuscles  through  the  walls  of  the  blood 
vessels,  no  holes  are  made  in  the  walls  of  these 
vessels,  neither  is  it  necessary  that  holes  are 
formed  in  the  epithelium  of  the  tonsil  when  lym- 
phocytes pass  through.  The  insult  to  the  epithe- 
lium by  the  current  loaded  with  lymphocytes 
does  not  produce  the  effect  that  microbes  get 
more  easily  into  the  tissues,  as  the  intervals  in 
the  epithelium  are  constantly  filled  with  the 
lymph  current,  and  the  possible  lesions  to  the 
epithelium  are  never  lasting  defects,  but  disap- 
pear as  soon  as  the  intensity  of  the  current  is 
diminished,  and  then  the  epithelium  layer  closes 
instantly.  It  seems  to  be  sufficient  that  the  clefts 
between  the  epithelium  cells  allow  the  lym- 
phocytes to  pass,  and  that  only  exceptionally,  as 
Stolir  has  pictured,  there  are  large  streaks  in  the 
epithelium  which  really  look  like  an  open  wound. 
I  was  compelled  to  make  these  foregoing  ex- 
planations, Frdnhel  remarks,  because  they  are 
important  in  studying  the  infectious  diseases  of 
the  pharynx. 

Jacohi  remarks  that  "clinical  observations  will 
rarely  be  numerous  enough  to  decide  the  exclus- 
ive or  partial  port  of  entry  of  a  poison  into  the 
circulation.  For  we  are  seldom  in  a  position  to 
separate  the  tonsil  from  its  neighborhood  during 
the  acute  invasion  or  the  rapid  progress  of  a 
microbic  or  toxic  poison."  He  states  that  "doz- 
ens of  years  ago  he  could  prove  that  diphtheria, 
when  limited  to  the  tonsils,  was  least  dangerous. 
That  the  thousands  of  other  lymph  bodies  dis- 


276  THE    TONSILS    AND    THE    VOICE 

seminated  in  the  fauces  and  posterior  nares  are 
more  guilty  than  the  two  dozen  which  form  the 
tonsils.  It  is  thej^  that  should  be  considered  in 
the  preventive  treatment  of  all  the  infectious  dis- 
eases of  childhood.  In  cases  of  membranous 
throat  disease,  whenever  the  membrane  is  limit- 
ed to  the  tonsil  there  is  little  or  no  glandular 
swelling  in  the  neighborhood.  On  the  other 
hand,  if  a  membrane  extends  from  the  tonsil  to 
its  neighborhood,  or  starts  at  a  distance  from 
the  tonsil,  neighboring  lymph  bodies  swell  at 
once.  These  clinical  observations"  Jacohi  states, 
"have  stood  the  test  of  time  and  must  he  reckoned 
with.  Microhic  invasion  through  the  tonsil  is 
not  ijredominant  over  that  which  takes  place 
through  the  lymph  apimratus  of  the  pharynx  J" 

"Almost  like  injection  material,"  Jacohi  con- 
tinues to  remark,  "living  invading  material  may 
enter  the  lymph  or  the  blood  circulation,  iwovided 
there  is  a  break  in  the  wall,  hut  not  with  the  same 
facility  as  injection  material  forced  in.  A  sur- 
face lesion  must  always  he  supposed  to  exist  when 
a  living  germ  or  toxin  is  to  find  access." 

"If  that  were  not  so,"  Jacohi  states,  "no  hu- 
man or  inferior  animal  could  exist  under  the 
clouds  of  microbes  and  toxins  surrounding  us. 
It  looks  rational,  therefore,  to  admit  that  when 
there  is  merely  a  surface  lesion,  though  ever  so 
slight,  there  may  be  an  invasion  into  the  tonsil. 
When,  however,  the  vessels  are  exposed  to  pres- 
sure hy  newly  formed  cells  or  tissue,  there  is  no 
invasion,  certainly  not  heyond  the  tonsil  itself, 
no  ganglionic  swelling,  and  no  toxic  poisoning. 


DIAGNOSIS  277 

It  is  even  rational  to  believe  that  now  and  then 
when  tonsils,  or  what  is  more  common,  a  single 
follicle,  becomes  inflamed,  the  very  venous  ob- 
struction will  eocert  the  bactericidal  influence  of 
the  stagnating  blood  serum." 

There  are  no  lymphatic  sinuses  around  the 
tonsil,  according  to  Retterer,  Labbe,  Hodenpyl 
and  3Iost. 

The  lymj)h  current  near  the  tonsil  is  less  active 
than  that  of  the  pharynx  at  some  distance,  ac- 
cording to  Labbe  and  Hodenpyl.  Retterer 
proved  that  the  periphery  of  the  lobules  of  the 
tonsil  is  more  vascular  than  the  centers. 

In  the  experiments  of  Lexer  the  emulsions  of 
bacteria  which  he  brushed  on  the  tonsils  only  oc- 
casionally entered  into  the  tonsillar  tissue.  Goerhe 
believes  that  in  the  experiments  of  Lexer  the 
infection  did  not  occur  through  the  tonsil  but 
through  other  parts  of  the  mucous  membrane  of 
the  pharynx. 

Menzer,  in  his  experiments  and  researches 
found  in  persons  who  suffered  from  acute  articu- 
lar rheumatism  streptococci  in  the  tonsils  only 
within  the  epithelium  layer  and  he  could  prove, 
on  the  other  hand,  that  a  larger  amount  of  infec- 
tious germs  were  present  in  the  connective  tissues 
surrounding  the  tonsils. 

Goodale  injected  carmine  powder  directly  into 
the  fossula  of  the  faucial  tonsil.  Upon  micro- 
scopic examination  he  found  carmine  powder 
within  and  underneath  the  epithelium.  Brieger 
and  Goerhe  do  not  consider  Goodale's  experi- 
ment free  from  objection.     The  colored  particles 


278  THE    TONSILS    AND    THE    VOICE 

were  injected  with  a  certain  energy.  How  can  we 
exclude  the  possibility  that  the  foreign  particles 
were  forcibly  put  into  the  tonsillar  tissue,  through 
tearing  the  epithelium;  but  granting,  says 
Goerke,  that  artificial  tearing  did  not  occur,  even 
then,  the  experiment  proves  nothing.  Is  it  not 
very  probable,  asks  Goerhe,  that  by  filling  up  a 
fossula  the  free  flow  of  the  lymphatic  fluid  is 
interfered  with,  and  therefore,  the  lymphatic  cur- 
rent which  can  flow  to  all  points  of  the  epithelium 
at  this  point  of  greatest  resistance  is  turned  and 
flows  to  many  other  points  of  lesser  resistance, 
taking  along  particles  of  the  foreign  material  in- 
jected into  the  fossula? 

Groher  demonstrated  the  comparative  absence 
of  a  direct  communication  of  the  tonsil  with  the 
rest  of  the  body  through  the  surrounding  fibrous 
capsule.  His  injections  into  the  tonsils  accumu- 
lated in  large  quantities  underneath  the  capsule. 
Thus  it  happened  that  the  organ  was  often  en- 
larged to  a  considerable  extent. 

In  order  to  diagnosticate  tonsillar  diseases  a 
knowledge  of  infectious  processes  is  absolutel}'- 
essential  as  well  as  a  knowledge  of  the  anatomy 
and  clinical  features  of  the  tonsil. 

The  mucous  membrane  of  the  mouth  harbors 
at  all  times  jlarge  numbers  of  cocci,  bacilli  and 
spirillae,  and  among  these  are  often  found  micro- 
organisms of  violent  character. 

The  infection  of  the  tonsil  from  its  outside 
surface  is  by  the  same  process  of  infection  that 
occurs  on  the  outside  surface  of  any  other  part  of 
the  body. 

There  is  no  proof  that  the  normal  epithelium 


DIAGNOSIS  279 

of  the  tonsil  ever  presents  an  open  wound,  as 
claimed  by  Stohr. 

There  is  no  proof  that  the  normal  tonsil  is  ever 
a  port  of  entry,  an  open  door,  for  infectious 
germs. 

There  is  no  proof  that  the  normal  tonsil  has 
any  absorbent  power  whatever. 

The  f  ossulae  of  the  tonsil  are  lined  with  mucous 
membranes  having  the  ordinary  function  of  other 
mucous  membranes  so  far  as  known. 

The  blood  supply  to  the  tonsil  is  scant;  and  it 
has  little  or  no  communication  with  Waldeyefs 
lymphatic  ring.  The  faucial  tonsil  differs  in 
anatomical  character  from  other  tonsils,  and  from 
other  lymphatic  tissues.  The  external  deep  sur- 
face is  encased  in  a  firmly  adherent,  strong, 
fibrous  sheath. 

Nothing  like  this  capsule  surrounds  any  other 
lymphatic  body.  So  dense  and  tendinous  and 
strongly  adherent  is  this  capsule  that  one  may 
consider  the  organ  as  being  armor-plated.  It  is 
not  perforated  by  lymphatics,  nerves,  arteries  or 
veins.  And  from  the  standpoint  of  diagnosis, 
and  the  possible  invasion  of  the  tonsil  by  the  in- 
fection process,  it  is  also  well  to  remember,  that 
the  capsule  sends  a  network  of  fibrous  tissue  as 
outrunners  along  the  walls  of  the  blood  vessels. 
The  capsule  also  sends  connective  tissue  into  and 
between  the  folds  of  the  mucosa. 

Thick  or  thin,  the  fibrous  sheath  is  firm  and 
solid.  That  is  why  abscesses  do  not  open  into 
the  maxillo-pharyngeal  space.  And  that  is  why 
it  is  difficult  for  bacteria  and  toxins  to  enter  the 
tonsil  from  that  point.     The  capsule  with  its  out- 


280  THE    TONSILS    AND    THE    VOICE 

runners  protect  the  tonsil  from  invasion.  The 
capsule  is  not  an  anatomical  accident.  It  is 
always  present. 

In  the  diagnosis  of  primary  disease  of  the  fau- 
cial  tonsil,  I  draw  attention  to  the  following 
points : 

1.  There  are  no  lymphatic  sinuses  round  the 
tonsil. 

2.  The  lymph  current  near  the  tonsil  is  less 
active  than  that  of  the  pharynx  at  some  distance. 

3.  The  tonsil  and  its  immediate  neighborhood 
are  inferior  in  regard  to  facilities  for  absorption 
to  the  rest  of  the  pharynx  and  nares. 

4.  There  is  a  comparative  absence  of  direct 
communication  of  the  tonsil  with  the  rest  of  the 
body  through  the  surrounding  fibrous  capsule. 

5.  We  must  distinguish  the  true  from  the  false 
hypertrophies:  the  merely  swollen  from  the  hy- 
perplastic organ. 

6.  It  is  necessary  to  distinguish  the  normal 
from  the  pathologic  organ. 

7.  Involution  is  an  expression  of  immunity 
against  certain  infections  peculiar  to  children. 
The  removal  of  simple  hypertrophic  tonsils,  as  a 
rule,  causes  no  febrile  reaction.  The  removal  of 
enchatoneed  tonsils,  as  a  rule,  causes  more  or  less 
febrile  reaction. 

8.  Persons  with  enlarged  tonsils  are  generally 
healthy. 

9.  The  number  of  newly  found  lymphocytes  is 
always  considerably  larger  in  the  hyperplastic 
tonsil  than  in  the  normal. 

10.  The   flow   of   lymphocytes    through    the 


DIAGNOSIS  281 

epithelium  to  its  surface  is  always  increased  when 
the  tonsil  is  enlarged. 

11.  Briegefs  suction  therapy  is  intended  to 
encourage  the  outward  flow  of  lymphocytes  from 
the  center  of  the  tonsil  to  the  surface  of  the 
epitheHum. 

12.  Acute  inflammation  of  the  tonsil  shows  an 
increased  infiltration  with  leucocytes  which  causes 
enlargement  of  the  organ,  also  an  increased 
amount  of  lymph  in  the  intercellular  spaces. 

13.  Not  only  do  the  faucial  and  pharyngeal 
tonsils  atrophy  normally  at  a  certain  age,  but  the 
same  change  occurs  at  the  same  time  in  the  lym- 
phatic tissues  of  the  digestive  tube. 

14.  Primary  disease  of  the  tonsil  is  favored  by 
bacterial  or  toxic  invasion  of  the  pharyngeal  se- 
cretions. 

15.  A  surface  lesion  must  always  exist  when 
a  germ  or  toxin  is  to  find  access. 

16.  When  the  vessels  of  the  tonsils  are  exposed 
to  pressure  by  newly  formed  cells  or  tissue,  there 
is  no  invasion. 

IT.  When  the  tonsil  or  a  single  follicle  be- 
comes inflamed,  the  venous  obstruction  will  ex- 
ert the  bactericidal  influence  of  the  stagnating 
serum. 

18.  Exposure,  and  many  diseases,  change  the 
structure  and  harden  the  surface  of  the  tonsil. 

19.  Cell  infiltration  and  cicatricial  tissue  render 
absorption  less  possible.  Blood  and  lymph  ves- 
sels are  compressed  and  undergo  atrophy.  The 
tonsil  becomes  harder  and  smaller  and  infections 
become  less.    It  is  well  known  that  with  increas- 


282  THE    TONSILS    AND    THE    VOICE 

ing  age  the  tendency  towards  the  commoner  ton- 
sillar inflammations  lessens. 

20.  The  so-called  acute  tonsillitis,  inflamma- 
tion of  the  lining  of  the  fossulae,  lacunar  tonsilli- 
tis, impaction  of  the  fossulae  with  debris  and  bac- 
teria, chronic  follicular  tonsillitis,  are  not  diseases 
of  the  tonsil.  They  affect  only  the  outside  sur- 
face of  the  organ. 

21.  Membranous  affections  limited  to  the  ton- 
sil cause  little  or  no  adenitis,  or  constitutional 
symptoms.  There  is,  therefore,  no  absorption 
from  the  surface  of  the  organ. 

22.  Primary  disease  of  the  tonsil  is  disease  that 
begins  at  or  in  the  tonsil. 

23.  We  have  assurance  that  disease  of  the  ton- 
sil is  primary  when  the  pharynx,  nares,  and  lar- 
ynx are  in  normal  condition. 

24.  Whenever  any  part  of  the  pharynx,  nares 
or  larynx  is  affected,  it  then  becomes  especially 
difficult  to  determine  whether  the  tonsil  affection 
is  primary. 

25.  When  cervical  adenitis  occurs,  we  must  not 
assume  that  absorption  took  place  through  the 
faucial  tonsil.  It  has  not  been  proved  that  the 
faucial  tonsil  absorbs.  But  all  authorities  agree 
that  the  thousands  of  lymphatic  glands  in  the 
pharynx,  nares,  and  larynx  are  very  active  ab- 
sorbents. Therefore,  whenever  cervical  adenitis 
occurs,  we  must  make  sure  in  every  case  that  no 
absorption  took  place  through  some  of  these  lym- 
phatic bodies.  To  prove  that  in  any  given  case, 
infection  entered  the  general  system  through  the 
faucial  tonsil,  it  is  necessary  to  prove  that  it  did 
not  enter  through  any  of  the  other  lymphatics  of 


DIAGNOSIS  283 

the  pharynx,  nares  or  larynx,  which  latter  are 
most  absorbent  when  in  norinal  condition. 
Otherwise^,  there  is  no  absolute  proof  that  any  in- 
fection entered  by  way  of  the  faucial  tonsil. 

If  no  disorder  is  visible  in  the  lymphatic  glands 
of  the  pharynx,  nares  and  larynx,  they  are  then 
in  the  best  possible  condition  for  active  absorp- 
tion. 

( 26 )  If  the  bacilli  of  tuberculosis  and  the  cocci 
of  rheumatism  are  to  be  found  in  the  peritonsil- 
lar tissues,  then  we  can  have  no  assurance  that 
these  tissues  did  not  absorb  the  respective  micro- 
organisms of  tuberculosis  and  of  rheumatism. 

(27)  If  the  tonsils  look  natural  in  color  and 
in  size,  then  the  adenitis,  and  the  absorption  of 
bacilli  and  cocci,  most  probably  took  place 
through  the  numerous  lymphatic  bodies  of  the 
pharynx  and  nares,  and  the  tonsil  cannot  be  held 
responsible ;  certainly  not  solely  accountable. 

(28)  The  faucial  tonsil  is  rarely  attacked  by 
suppuration:  there  exist  suppurative  follicles, 
but  the  interstitial  tissue  itself  does  not  suppu- 
rate. 

Tonsillitis  with  suppuration  means,  in  the  vast 
majority  of  cases,  peritonsillitis.  It  is  the  peri- 
tonsillar tissue  which  forms  the  abscess,  and  most 
frequently  it  is  at  the  superior  pole  of  the  tonsillar 
loge  where  the  pus  is  sought. 

(29)  It  has  been  proved,  both  microscopically 
and  macroscopically,  that  the  tonsil  is  very  often 
only  in  part  affected,  not  the  whole  organ. 


284  THE   TONSILS   AND   THE   VOICE 

Secondary. 

Any  disease  of  the  tonsil  arising  from  disease 
in  another  locahty,  either  by  continuity  of  sur- 
face, or  by  direct  communication  via  the  lymph 
or  blood  vessels,  is  secondary  to  the  latter  affec- 
tion. The  great  majority  of  tonsillar  diseases) 
are  secondary  affections. 

The  tonsil  may  be  secondarily  infected  hy  mi- 
crohic  penetration  of  its  surface.  For  example, 
in  peritonsillar  abscess  the  micro-organisms  in- 
vade the  tissue  surrounding  the  tonsil,  causing 
an  inflammation  which  leads  to  penetration.  It 
is  less  known  that  this  not  only  occurs  on  the 
faucial  tonsil,  but  on  all  other  tonsils. 

On  the  base  of  the  tongue,  inflammations  occur 
which  affect  the  epiglottis,  taking  their  origin 
from  angina  of  the  lingual  tonsil.  This  is  not 
rare.  Angina  of  the  pharyngeal  tonsil  has 
caused  abscess  in  the  naso-pharynx. 

The  tonsil  may  be  secondarily  infected  from 
the  blood,  the  lymphatic  vessels  carrying  in- 
fected  material  to  the  inside  of  the  tonsil.  It  is 
important  to  know  that  the  tonsils  can  be  in- 
fected via  the  blood  and  lymphatic  vessels  just  as 
from  the  surface.  Secondary  infection  from  its 
surface  is  the  same  as  in  other  parts  of  the  body. 
Infection  from  the  blood  has  not  been  sufficiently 
considered.  Frederici  and  Goerke  have  given 
experimental  proofs  of  the  infection  of  the  tonsil 
from  the  blood. 

Secondary  infection  of  an  organ  means  noth- 
ing else  but  that  germs  circulating  in  the  blood  or 
lymph  current  find  conditions  in  this  organ 
favorable  to  their  settlement. 


DIAGNOSIS  285 

Lately,  experiments  have  been  published  by 
Von  Lendrt  which  proved  the  statement  of 
Frdnkel  that  secondary  infection  of  the  faucial 
tonsil  follows  operations  in  the  nose.  Von  Le- 
ndrt has  proved  that  the  lining  of  the  nose  is 
directly  connected  by  lymphatic  vessels  with  the 
center  of  the  tonsils.  We  are  sure  infectious 
material  is  carried  to  the  tonsil  from  the  nose. 

Very  commonly  in  my  daily  practice,  in  many 
cases,  I  have  observed  swollen,  tender  and  pain- 
ful faucial  tonsils,  following  an  attack  of  acute 
coryza.  And  I  have  demonstrated  to  many  phy- 
sicians, in  many  cases  of  exacerbation  of  chronic 
nasal  catarrh,  the  immediate  improvement  and 
the  prompt  subsidence  of  the  tonsillar  condition 
after  cleansing  and  sterilizing  the  nares. 

While  the  tonsils  are  infected  mostly  from  the 
nose,  via  the  lymphatic  vessels,  they  are  also  in- 
fected via  the  blood  and  lymphatic  vessels  with 
tuberculosis.  These  latter  cases  belong  mostly  to 
the  latent  tuberculosis.  The  children  are  com- 
paratively healthy.  They  are  only  troubled  by 
the  hyperplasia  of  the  tonsils,  either  in  the 
pharynx  or  in  the  throat.  In  the  tissue  of  the 
amputated  tonsil  we  find  tubercular  nodules  or 
bacilli;  we  often  find  also  in  children  swelling  of 
the  glands  of  the  throat.  These  children  appear 
scrofulous  and  we  can  assume  that  the  swelling 
of  the  glands  is  caused  by  resorption  of  the 
nodules  of  tubercular  bacilli  in  the  tonsils.  If 
we  make  tuberculin  injections  in  children,  we  can 
often  show  a  local  reaction  in  the  pharyngeal 
tonsil.  If  these  children  show  a  general  re- 
action, nothing  is  proved,  as  they  might  have 


286  THE    TONSILS    AND    THE    VOICE 

tuberculosis  in  other  parts  of  the  body,  but  if  one 
sees  in  such  cases  that  the  tonsils  show  a  local 
reaction  one  can  make  the  latent  tuberculosis  a 
manifest  one. 

There  is  a  primary  lupus  of  the  pharynx  as 
also  a  primarj^  miliarj'-  tuberculosis,  but  in  most 
cases  these  are  secondary.  I  believe  it  sufficient 
if  you  consider  these  forms,  the  latent  one,  the 
visible  tuberculosis  which  is  seen  sometimes  as 
miliary  tuberculosis  and  at  other  times  as  lupus. 

Symptomatic. 

As  a  matter  of  diagnostic  convenience,  the  ton- 
sillar manifestations  of  constitutional  diseases, 
such  as  general  tuberculosis,  and  of  scarlet  fever, 
measles,  etc.,  may  be  termed  symptomatic,  in  con- 
tra-distinction  to  secondary  affections  that  may 
be  rather  directly  traced  to  another  locality. 
There  should  be  little  trouble,  generally,  in  the 
recognition  of  symptomatic  conditions. 

Refiecc. 

The  subject  of  tonsil  reflex  is  very  complex 
and  very  obscure.  The  faucial  tonsil  is  well  situ- 
ated and  admirably  equipped  for  reflex  effects, 
through  its  connection  with  the  fifth,  ninth  and 
sympathetic  nerves. 

Reflex  processes  involve  not  alone  the  sympa- 
thetic nervous  system,  but  ^hey  include  as  well 
the  motor  and  sensitive  nerves;  and  their  prob- 
lems are  proportionately  intricate. 

The  remarks  of  Jonathan  Wright,  in  his  work 
on  the  "Nose  and  Throat  in  Medical  History f^  on 
the  subject  of  reflex  nasal  neuroses,  may  be  per- 


DIAGNOSIS  287 

fectly  well  applied  to  reflex  tonsil  neuroses: 
"How  grossly,  after  a  few  years,  this  subject 
was  exaggerated  and  distorted  is  apparent,  now 
that  the  exaggeration  is  decreasing." 

And  LerjnoyeZj,  in  an  article  on  '^'^ Accidents 
Which  Follow  Nasal  Operations"  states: 
"Tardy,  but  fatal,  the  reaction  has  set  in  against 
the  excessive  operations  which  have  followed  an 
exaggerated  generahzation  of  the  discoveries  of 
Voltolini  and  of  Hack.  In  the  concert  of  preco- 
cious enthusiasm,  some  discordant  voices  had 
much  difficulty  in  making  themselves  heard. 
Times  have  changed.    Now,  silence  has  come." 

Frdnkel,  inaugurating  the  laryngological  sec- 
tion of  the  Congress  at  Berlin,  said:  "The  study 
of  nasal  reflexes  seems  for  some  time  past  a  little 
neglected  by  the  specialists.  The  thing  is  not  re- 
grettable ;  it  concerns  the  future  of  this  specialty 
that  it  proceeds  with  calmness  and  avoids  every 
dangerous  impetuosity.  We  will  thus  assure  the 
good  of  patients,  and  above  all,  the  confidence  of 
the  great  medical  public  in  our  specialty." 

Charles  P.  Grayson,  in  the  Medical  Record, 
December  12,  1908,  states:  "I  am  very  much  of 
the  opinion  that  before  any  further  addition  is 
made  to  the  list  ( of  reflex  disturbances  for  which 
the  nose  has  been  held  responsible)  the  founda- 
tion upon  which  it  rests  should  be  critically  exam- 
ined to  see  if  it  be  secure  enough  even  to  support 
the  strain  to  which  it  has  already  been  subjected." 

Sir  Felias  Semon,  in  his  work  on  "Diseases  of 
the  Upper  Air  Passages,"  says:  "We  come  to 
the  subject  of  'nasal  reflex  neuroses';  in  my  hum- 
ble opinion  one  of  the  most  unsatisfactory  in 


288  THE    TONSILS    AND    THE    VOICE 

modern  medicine.  In  my  experience,  our  knowl- 
edge with  regard  to  diagnosis  and  our  results 
with  regard  to  treatment  of  nasal  reflex  neuroses 
are  still  extremely  unsatisfactory." 

Tlie  words  of  Wright,  Lermoyez,  Frdnkel, 
Grayson  and  Semon  apply  with  equal  force  to 
the  tonsils.  In  fact,  they  apply  to  these  organs 
with  more  than  equal  force,  pr^oviding  that  the 
cavernous  condition  favors,  and  the  congestion 
of  the  erectile  tissue  of  the  nasal  mucosa  depends 
upon  reflex  action.  Without  cavernous  and 
erectile  tissue,  there  would  pi^ohahly  he  less  vaso- 
motor excitement,  and  consequently  less  action  of 
reflex  character. 

The  faucial  tonsils  may  suffer  from  reflex 
neuroses. 

Affection  of  the  faucial  tonsil,  as  a  result  of 
reflex  from  a  distant  part,  is  a  new  study.  Not 
one  case  of  the  kind  has  ever  been  reported.  The 
subject  is  not  mentioned  in  any  work  on  physiol- 
ogy, nor  in  the  textbooks  of  Wright,  Knight, 
Ballenger,  Escat,  Moure,  Coakley,  Grayson, 
Kyle,  Bosworth,  Browne,  Chiari,  Castex,  Fred- 
erici,  Gruenwald,  Wlacheiizie,  Seiler,  Sajous, 
Shurly,  Williams,  Burnett,  Cohen,  hi  gals,  nor 
by  any  other  writer,  as  far  as  I  have  been  able  to 
ascertain. 

The  subject  has  been  wholly  neglected,  hut  is 
hound  to  heconie  more  vital  with  time.  Skilled 
diagnosticians  will  regard  the  matter  with  in- 
creasing importance,  in  view  of  the  teachings  ( 1 ) 
of  Frdnkel,  Brieger,  Goerke,  and  others,  that  the 
tonsils  are  important  protective  organs ;  ( 2 )  that 
according    to     Von    Lendrt,    Poli,    Frederici, 


DIAGNOSIS  289 

Frdnkel,  Von  Levinstein  and  others,  they  are  fre- 
quently affected  in  a  secondary  way,  from 
nasal  trauma;  (3)  of  the  teachings  of  Miller, 
Van  Baggen,  Moure,  Laniperti  and  others,  that 
they  have  mechanical  functions ;  and  ( 4 )  that  on 
the  other  hand,  their  complete  re7noval  is  advised 
as  an  ordinary  routine  by  most  American  opera- 
tors. 

It  is  no  doubt  true  that  every  natural  anatom- 
ical structure  in  the  throat,  every  muscular  fibre, 
every  nerve  filament,  every  lymphatic  gland,  has 
a  physiological  function. 

The  very  latest  advances  in  pathology  and  in 
biological  chemistry  must  be  drawn  upon,  for 
there  is  exceedingly  great  danger  of  confoundiiig 
secondary  diseases  with  reflex  trouble.  An  exact 
differential  diagnosis  must  be  made,  a  positive 
line  of  demarcation  must  be  drawn  between  those 
diseases  which  are  supposed  to  be  reflex,  and 
those  which  Frdnkel,  Von  Lendrt  and  other  in- 
vestigators have  proved  to  be  due  to  secondary 
absorption  from  nasal  trauma. 

By  the  law  of  reflex  action,  reflexes  must  be 
capable  of  extending  in  either  direction,  with 
equal  ease  and  facility.  If  a  lesion  of  the  faucial 
tonsil  is  capable  of  provoking  reflex  disturbance 
in  a  distant  part,  then  the  tonsil  must  be  subject 
to  reflex  influence  from  the  identical  distant  part. 

The  trifacial  and  glosso-pharyngeal  nerves  are 
extremely  sensitive.  They  both  send  branches 
to  the  faucial  tonsil.  So  does  the  sympathetic 
nerve.  Any  affection  of  these  nerves  may,  by 
the  law  of  reflex,  provoke  disturbance  of  the 
faucial  tonsil.     The  trifacial  is  the  sensory  nerve 

20 


290  THE    TONSILS    AND    THE    VOICE 

of  the  mucous  membrane  of  the  nose  and  of  its 
accessory  cavities;  and  it  sends  sensory  branches 
to  the  organ  of  hearing.  The  trifacial  is  respon- 
sible for  the  radiation  to  the  ears  of  pains,  which 
have  their  origin  in  the  naso-pharynx,  the  pillars 
of  the  fauces,  the  lateral  walls  of  the  pharynx, 
the  tongue  and  the  f  aucial  tonsils. 

The  f aucial  tonsil  is  sometimes  affected  as  a 
reflex  from  a  distant  part.  The  author  has  fre- 
quently noted  cases  of  pain,  vasomotor  disturb- 
ance, acute  swelling  and  hyperplasia,  which 
appeared  to  be  of  reflex  origin.  Some  of  the  so- 
called  "rheumatic  tonsils^'  appear  more  like  reflex 
vasomotor  disturbance;  and  some  of  those  cases 
called  "rheumatic"  are  certainly  instances  of 
secondary  disturbance  from  the  absorption  of  the 
morbid  material  of  nasal  catarrh. 

"Pain  in  any  part,  when  not  associated  with  in- 
crease of  temperature,  must  be  looked  upon  as 
sympathetic  pain,  caused  by  an  exalted  sensitive- 
ness of  the  nerves  of  the  part,  and  it  is  to  be  re- 
garded as  a  pain  depending  upon  a  cause  situated 
remotely  from  the  part  where  it  is  felt."  (John 
Hilton,  "Rest  and  Pain") 

It  is  not  uncommon  to  see  the  f aucial  tonsil 
congested  and  painful  without  apparent  cause. 
There  is  no  reason  why  pain  may  not  occur  as  a 
symptom  of  hysteria.  In  a  number  of  cases  the 
author  has  observed  a  painful  condition  of  the 
faucial  tonsil  associated  as  a  reflex  with  painful 
affection  of  the  nares.  And  in  one  case  during 
the  progress  of  necrosis  in  a  molar  tooth,  at  each 
and  every  exacerbation  of  trouble  in  the  tooth, 
pain  developed  in  the  tonsil;  and  every  time, 


DIAGNOSIS  291 

after  the  tooth  had  been  treated,  the  pain  in  the 
tonsil  subsided,  until  finally,  after  the  tooth  was 
cured,  the  pain  in  the  tonsil  permanently  ceased. 
It  is  a  common  experience  for  the  j  aw  to  become 
stiffened  with  all  the  muscles  of  the  pharynx 
firmly  set,  and  pressing  on  the  tonsil,  pushing  it 
out  of  its  natural  position,  and  causing  pain  in  it, 
as  well  as  in  the  whole  region  of  the  condyle — as 
a  reflex  condition  from  bad  teeth. 

Reflex  spasm  and  congestion  are  sometimes 
the  measures  of  nature  to  protect  injured  parts. 
I  have  seen  this  especially  in  cancer. 

It  is  a  common  experience  for  pain  to  shoot 
into  the  ear  when  the  faucial  tonsil  is  touched 
with  a  probe,  painted  with  iodine,  or  touched 
with  an  electric  point.  Pain  produced  by  carious 
teeth  is  often  felt  in  the  tonsil,  temple,  or  the  ear. 

But,  in  every  case  of  suspected  tonsil  reflex 
neurosis,  whether  from,  or  to,  the  organ,  until 
proved,  should  be  viewed  with  doubt. 

Reflex  neuroses,  as  manifestations  of  hysteria, 
are  of  very  common  occurrence.  Almost  every 
disease  may  be  simulated  by  hysteria.  Anaesthe- 
sia, complete  loss  of  hearing,  smell  and  taste, 
may  occur  due  to  hysteria.  The  mucous  mem- 
brane of  the  nose,  mouth  and  larynx  become 
analgesic  from  the  same  cause.  The  muscles  af- 
fecting the  voice  may  be  affected  in  hysteria, 
causing  complete  loss  of  voice. 

The  hysterical  barking  cough  is  a  good  exam- 
ple of  reflex.  Hysterical  cough,  by  the  irrita- 
tion which  it  produces,  will  sometimes  cause  or- 
ganic disease  of  the  throat. 

Hysterical  aphonia  without  paresis,  without 


292  THE    TONSILS    AND    THE    VOICE 

inflammation,  without  any  apparent  laryngeal 
irritation,  is  not  uncommon. 

I  was  consulted  recently  by  a  contralto  whose 
glorious  singing  voice  was  entirely  lost  through 
fear  of  repeated  criticism.  The  whole  respira- 
tory tract  was  absolutely  normal.  It  was  a  case 
of  pure  psj^chic  reflex. 

Contraction  of  the  wound  after  removal  of  the 
tonsils  is  sometimes  very  great,  and  extensive  ad- 
hesions often  form,  leading  to  distortion  of  the 
parts  and  over  stretching  of  the  mucous  mem- 
branes, and  providing  endless  reflex  actions. 

Sahli,  ''Diagnostic  Methods/"  1906,  states: 
''Pain  may  he  subdivided  into  parenchymatous 
and  neuralgic.  In  imrenchymatous  pains  the 
sensory  fibres  are  irritated  at  their  terminal  rami- 
fications, in  neuralgic  pains,  at  the  trunks  of  the 
sensory  or  mixed  nerves,  in  the  sensory  roots  or 
in  the  sensory  centers." 

"In  the  former,  the  termination  of  the  sensory 
fibres  are  irritated  quite  independently  of  their 
organ,  and  therefore  the  pains  overlap  the  boun- 
daries of  peripheral  sensory  areas,  apparently  at 
will." 

"Neuralgic  pains,  on  the  contrary,  according 
to  the  law  of  eccentric  projection,  are  localized 
in  areas  that  correspond  exactly  to  the  peripheral 
distribution  of  the  nerve  trunk  or  nerve  involved. 
Pain  may,  however,  be  felt  in  neighboring  nerve 
territories  from  irradiation  of  the  pain  from  the 
involved  nerve  into  them." 

"Neuralgic  pains  are  generally  much  more  se- 
vere than  parenchymatous  pains,  for  the  reason 
that  in  the  former  a  much  larger  number  of  fibres 


DIAGNOSIS  293 

are  painfully  irritated,  and  ordinarily  at  the  same 
moment.  Probably  for  the  same  reason  remis- 
sions in  a  severe  pain  are  more  decided  in  neu- 
ralgic than  in  parenchymatous  pain.  Another 
distinction  is  that  generally  with  parenchymatous 
pains  the  entire  painful  area  is  sensitive  to  pres- 
sure. This  is  sometimes  the  case  with  neuralgic 
pains;  but,  as  a  rule,  only  that  portion  of  the 
nerve  trunk  is  sensitive  to  pressure  which  lies 
superficial  or  upon  a  hard  foundation  (neuralgic 
pressure  points)." 

"So-called  sympathetic  or  refleoc  sensation  is 
related  to  hyperalgesia.  The  best  known  of  this 
is  pain  irradiation,  in  which  the  pain  is  perceived 
far  beyond  the  limits  of  the  painfull}^  irritated 
peripheral  part  (pain  in  the  entire  trigeminal 
distribution,  occasioned  by  a  single  carious 
tooth).  This  phenomenon  can  be  explained 
only  hy  assuming  that  the  painful  stimulation  in 
the  central  organs  overlaps  or  irradiates  to  neigh- 
boring tracts  by  means  of  dendrites  and  collat- 
erals, and  that,  in  accordance  with  the  law  of 
eccentric  projection,  confusion  as  to  the  origin  of 
the  perception  results." 

"The  pain  sense  is  not  always  concerned  in  re- 
flexes either  of  primary  or  secondary  nature." 

''In  testing  reflexes,  it  is  advisable  to  distract 
the  patient's  attention  as  much  as  possible  from 
the  parts  under  examination.  The  simplest 
device  is  to  direct  him  to  close  his  eyes.  The 
fatigue  of  a  reflex  is  sometimes  responsible  for 
mistakes  in  diagnosis.  It  is  a  safe  rule  to  ob- 
serve each  reflex  quickly  and  accurately,  and  to 
utilize  repeated,  carefid  examinations  in  order  to 


294  THE    TONSILS    AND    THE    VOICE 

discriminate  in  any  doubtful  case,  for  the  reflexes, 
like  other  nervous  functions,  often  vary  at  dif- 
ferent times /^ 

"Ordinarily  reflexes  are  local  in  character,  id 
est,  they  take  place  in  the  region  of  the  body  that 
is  irritated.  But  with  an  increase  in  the  reflex 
irritability,  which  may  be  partly  within  the  nor- 
mal physiologic  limits  and  depend  partly  upon 
reflex  stasis,  the  reflexes  may  be  diffused  in  cross 
and  longitudinal  directions  to  other  muscle  areas 
and  to  other  extremities.  This  corresponds  to 
Pflilger's  laws  of  reflex  dispersion.  Increase  of 
the  reflexes,  as  well  as  decrease  or  absence  and 
qualitative  abnormalities,  are  {the  so-called 
pathologic  reflexes)  of  considerable  importance 
for  diagnosis." 

"Formerty  it  was  believed  that  the  spinal  cord 
was  the  center  of  all  reflexes.  Modern  neuro- 
pathologists, however,  following  the  teaching  of 
Bastian,  endeavor  to  dethrone  the  cord  from  its 
position  as  a  reflex  organ." 

"According  to  Jendrassik,  there  are  spinal  and 
cerebral  reflexes,  as  well  as  a  combination  of  the 
two,  id  est,  reflexes  requiring  both  cerebral  and 
spinal  centers  for  their  normal  performances." 

(1)  'SPINAL  REFLEXES.  This  divi- 
sion includes  tendons,  periosteal  and  joint  re- 
flexes. Their  characteristics  are  as  follows: 
(a)  They  are  generally  discharged  from  parts 
which  possess  little  sensation,  (b)  The  reflex  is 
associated  with  no  particular  feeling,  (c)  The 
discharge  takes  place  by  means  of  a  simple  me- 
chanical irritation,  such  as  a  blow,  (d)  The  in- 
tensity of  the  reflex  depends  upon  the  intensity 


DIAGNOSIS  295 

of  the  irritation,  not  upon  its  duration,  (e)  The 
reflexes  are  quite  as  easily  excited  in  ourselves  as 
in  others,  (f)  The  latent  time  of  the  reflex, 
corresponding  to  its  origin  in  the  spinal  cord,  is 
the  shortest,  (g)  The  ensuing  movement  is  a 
very  simple  one  and  serves  a  recognizable  pur- 
pose, (h)  Making  other  muscles  tense  increases 
the  reflex,  (i)  Slowing  of  these  reflexes  never 
occurs  pathologically,  (j)  Psychical  influences 
have  no  effect  upon  these  reflexes  aside  from  dis- 
traction of  attention,  which  increases  them." 

(2)  "CEREBRAL  REFLEXES.  These 
are  to  a  large  extent  the  cutaneous  refleoces.  The 
palatal  and  conjunctival  reflexes  belong  to  this 
group.  Their  characteristics  are  as  follows: 
(a)  They  are  discharged  from  sensitive  spots 
which  are  not  ordinarily  accustomed  to  a  light 
touch  (tickling),  (b)  The  liberation  is  asso- 
ciated with  a  specific  sensation  (prickings,  cold, 
tickling,  etc.).  (c)  Brief  stimulation  is  effica- 
cious for  their  liberation,  (d)  A  light  touch  has 
often  a  more  vigorous  action  than  a  stronger  one ; 
individuality  has  a  decided  influence,  (e)  These 
reflexes  can  scarcely  ever  be  liberated  by  the  per- 
son himself,  and  then  only  very  slightly,  (f) 
The  latent  time  is  longer  and  not  as  constant  as 
with  the  spinal  reflexes.  It  is  quite  independent 
upon  the  sensation  time  and  corresponds  to  the 
reaction  time,  id  est,  the  time  which  the  voluntary 
reaction  demands  of  a  sensory  stimulation,  (g) 
The  resulting  movement  is  simple,  and  its  prin- 
cipal characteristic  is  that  it  shows  an  effort  to 
escape  from  the  irritation,  (h)  Increased  activ- 
ity of  other  muscles  never  increases  the  reflex, 


296  THE    TONSILS    AND    THE    VOICE 

but  may  even  diminish  it.  (i)  These  reflexes 
are  diminished  on  the  paralyzed  side  in  cerebral 
hemiplegia,  (j)  They  are  delayed  in  cases  of 
delayed  sensation,  (k)  Psychical  influences  can 
either  diminish  or  even  increase  these  reflexes; 
distraction  of  the  attention  impairs  them." 

"(3)  COMPLEX  REFLEXES.  To  this 
group  belong  reflexes  which  have  complicated  cen- 
ters, within  which  the  reflex  occurs,  not  as  a  single 
movement,  but  as  a  series  of  such,  as  sneering, 
vomitings  swallowing,  coughing,  etc.  The  char- 
acteristics in  common  are  as  follows:  (a)  They 
are  liberated  from  sensitive  places,  (b)  The  hb- 
eratioii  takes  place  with  a  specific  sensation,  which 
plays  even  a  greater  role  in  the  origin  of  the  re- 
flex than  in  those  of  the  cerebral  group,  (c)  The 
hberation  requires  protracted  stimulation,  (d) 
Individuality  has  a  great  influence  upon  the  oc- 
currence of  the  reflexes.  (e)  The  stimulation 
which  produces  these  reflexes  is  a  specific  and 
complicated  one.  (f)  The  latent  time  is  longer 
than  for  any  of  the  other  reflexes,  (g)  The  re- 
sulting movement  is  very  complicated  and  bilat- 
eral: small  muscle  groups  take  part,  and  in  some 
of  them  the  reflexes  act  antagonistically,  (h) 
Muscular  activity  produces  a  certain  enfeebling 
in  their  action,  (i)  Psychical  influences  produce 
a  great  effect,  (j)  Reflexes  of  this  group  belong 
to  the  vegetative  functions." 

"The  distinction  between  groups  3  and  2  is 
essentially  this :  in  the  latter  the  sensation  is  trans- 
posed directly  into  simple  reflex  movement; 
whereas  in  the  former  the  sensation,  i.e. :  the  cor- 
tical stimulation  first  of  all  excites  a  complicated 


DIAGNOSIS  297 

reflex  center  to  activity.  This  center  is  composed 
of  different  separate  centers,  and  within  the  main 
center  the  reflex  process  then  takes  an  indepen- 
dent course." 

"The  demonstration  of  the  presence  of  a  rejieoc 
is  of  greater  diagnostic  significance  than  the 
demonstration  of  its  absence,  because  its  presence 
is  conclusive  evidence  of  an  intact  refieoo  arc; 
whereas,  although  its  absence  may  mean  that  the 
arc  is  interrupted,  it  may  also  mean  that  the  re- 
flex is  affected  by  a  nerve  inhibition  or  by  remote 
influence  from  some  circulating  disturbance. 
Similarly,  an  increase  of  a  reflex  is  ambiguous. 
The  latter  Tuay  be  caused  by  lesions  which  directly 
stimulate  the  reflex  centers  or  tracts,  or  by  those 
which  remove  inhibition  or  injure  inhibitory 
fibres.  The  pathologic  relations  of  the  reflexes 
are,  therefore,  evidently  complicated." 

We  know  so  httle  about  the  vasomotor  rela- 
tions in  nervous  diseases  that  it  is  scarcely  worth 
while  to  enter  upon  a  general  discussion. 

While  it  is  a  common  assertion  that  cicatrices, 
deformities,  and  altered  secretions,  provoke  re- 
flex lesions;  on  the  other  hand,  there  is  evidence 
to  show  that  abnormal  conditions  at  times  pre- 
vent by  reflex  action  the  development  of  distant 
neuroses.  MacDonald  has  recorded  a  case  of 
complete  nasal  obstruction  for  ten  or  twelve 
years,  in  which  severe  bronchial  asthma  developed 
six  weeks  after  the  restoration  of  free  nasal 
breathing".  Circumstances,  which  one  might  or- 
dinarily judge  would  provoke  reflex  actions,  many 
times  do  not.  Instance,  for  example,  the  two  fol- 
lowing remarkable   cases.    Krause  reports   the 


298  THE    TONSILS    AND    THE    VOICE 

case  of  a  tenor  whose  glottal  lips  looked  like  two 
ridges  of  red  flesh,  and  whose  tones  appeared 
nevertheless  unusually  sweet  and  soft.  And  Im- 
hofer  observed  a  singer  with  hypertrophy  of  one 
of  the  ventricular  bands  so  that  the  glottal  lip 
appeared  as  only  a  small  edge  beneath  the  heavy 
mass  of  the  ventricular  band  resting  upon  it ;  with 
this  apparently  unavailable  larynx,  he  is  a  suc- 
cessful tenor  on  one  of  the  largest  German 
stages. 

The  natural  reflex  action  of  the  normal  faucial 
tonsil  may  be  impaired  by  operative  interference. 

In  the  investigation  of  tonsil  reflexes  it  is  a 
safe  rule  to  take  nothing  for  granted.  Demand 
proof  for  everything. 

"How  greatly  would  the  number  of  operations 
on  the  tonsils  diminish  if  only  those  which  neces- 
sity imposed  were  performed,  and  above  all,  if  in 
the  treatment  of  the  nervous  accidents  called  re- 
flexes, one  addressed  himself  to  the  primary  cause 
of  all  the  trouble,  to  neurasthenia,  dyspepsia,  etc., 
and  not  to  the  tonsil  lesion,  which  most  frequently 
is  only  between  the  cause  and  the  effect  merely  a 
negligible  intermediary."    (Lermoyez.) 

Before  permitting  the  faucial  tonsil  to  be  re- 
moved, absolute  clinical  proof  should  be  demand- 
ed that  the  disease  from  which  it  suffers  is  not 
reflex  nor  secondary.  And  on  the  other  hand, 
clinical  proof  should  be  demanded  for  all  al- 
leged reflexes  from  the  tonsil,  namely:  that  they 
can  only  be  produced  as  reflex  neuroses  from  the 
faucial  tonsil;  that  they  may  be  completely  ar- 
rested by  anaesthesia  of  the  tonsil ;  and  that  they 
can  only  be  cured  by  direct  treatment  of  the  ton- 


DIAGNOSIS  299 

sil.  These  points  must  be  insisted  upon  in  all 
doubtful  cases. 

MECHANICAL.  By  reference  to  that  part 
of  my  chapter  on  physiology  which  treats  of  the 
mechanical  functions  of  the  f aucial  tonsil,  I  will 
save  repetition  here  of  matter  which  bears  upon 
the  diagnosis  of  its  mechanical  diseases. 

In  my  chapter  on  physiology,  I  have  dwelt  at 
great  length  on  the  mechanical  affections  of  the 
faucial  tonsil  to  show  the  great  difficulties  that 
lie  in  the  way  of  correct  diagnosis.  But  the  in- 
telligent interpretation  of  all  these  affections  of 
the  tonsil  and  voice  must  be  enforced,  if  we  wish 
to  preserve  respect  for  our  science. 

Mechanical  affections  of  the  tonsil,  associated 
with  the  mis-use  of  the  voice,  are  beyond  the  ken 
of  the  medical  profession. 

Maladies,  for  example,  of  the  timbre  of  the 
voice,  of  the  middle  register,  of  solidity,  intensity, 
compass,  agility,  the  tremolo,  etc.,  do  not  belong 
to  the  consideration  of  physicians. 

Many  years  of  experience  as  an  expert  laryn- 
gologist,  and  the  careful  examination  of  many 
thousands  of  patients  with  diseases  of  the  nose, 
throat  and  lungs,  enables  me  to  endorse  Castex 
when  he  states  that: 

"It  often  happens  that  we  are  consulted  by 
professional  voice  users,  in  whom  the  examina- 
tion of  the  larynx,  and  of  the  entire  vocal  ap- 
paratus, nasal  fossae,  pharynx,  trachea,  bronchia 
and  lungs,  does  not  reveal  to  us  anything  but 
small  lesions  and  sometimes  nothing.  The  various 
troubles  of  which  these  patients  complain  are  not 
found  in  any  known  pathology.    In  some,  'the 


300  THE    TONSILS    AND    THE    VOICE 

medium  is  out  of  balance,'  or  the  'transition'  is 
missed,  or  'they  no  longer  have  any  mezzo-tone,' 
etc.  These  are  difficult  cases  for  the  laryngolo- 
gist.  There  may  be  vocal  trouble  while  the 
larynx  remains  immune.  On  the  contrary,  an  ex- 
cellent voice  may  be  up  to  par  with  a  larynx  in 
bad  condition.  I  have  seen  the  cords  thick,  red, 
presenting  all  the  symptoms  of  corditis,  in  artists 
in  whom  the  voice  gave  no  trouble.  Krause  and 
others  have  made  the  same  observation." 

"To  disentangle  voice  maladies  is  not  easy,  in 
spite  of  the  knowledge,  zeal,  and  reflection  that 
one  may  bring  to  it." 

"The  diagnosis  of  a  malady  of  the  voice  is 
difficult.  Every  laryngologist  has  been  a  witness 
to  the  discouragment  of  singers,  when  their  voice 
is  in  jeopardy.  It  is  in  such  cases  that  a  good 
professor  of  singing,  or  elocution,  will  indicate 
the  causes.  A  rational  method  in  singing,  or 
speaking,  counts  for  much." 

"Patients  submit  for  years  at  a  time  to  cauter- 
ization of  the  nasal  mucosae,  resection  of  the 
horns  or  spurs,  galvano-cautery  of  the  pharynx, 
cauterization  and  massage  of  the  larynx,  removal 
of  tonsils,  etc.  Then  they  complain  that  all  the 
treatment  has  accomplished  nothing.  The  doctor, 
in  these  cases,  compromises  the  credit  of  laryn- 
gology." 

"The  treatment  to  pursue  in  vocal  cases  is  not 
always  evident." 

In  all  matters  pertaining  to  the  voice,  it  must 
be  distinctly  understood  that  voice  mechanicians, 
expert  larjaigologists,  and  experienced  voice 
tramers,  the  teachers  of  singing  and  the  teachers 


DIAGNOSIS  301 

of  elocution,  are  the  voice  authorities;  they  are 
the  men  who  know,  the  men  who  represent  the 
voice  profession.  And  it  must  be  clearly  recog- 
nized that  in  all  matters  pertaining  to  the  voice, 
the  ordinary  throat  specialists,  the  laryngecto- 
mists,  and  the  general  medical  profession  repre- 
sent nothing  but  the  laity.  The  medical  profes- 
sion is  the  laity  to  the  voice-profession  in  inatters 
of  the  voice. 

There  are  charlatans  in  the  voice  profession,  as 
in  every  other  profession,  but  cast  them  aside,  and 
take  the  scholarly,  conscientious,  and  experienced 
voice  teachers,  those  trained  to  teach,  for  their 
knowledge  of  the  voice  and  its  affections. 

It  is  beyond  the  knowledge,  and  absolutely  out 
of  the  sphere  of  physicians  to  judge  of  maladies 
of  the  timbre  of  the  voice,  of  affections  of  the 
middle  register,  of  the  solidity,  intensity,  com- 
pass, agility,  etc.,  etc.  Mechanical  affections  of 
the  tonsils  associated  with  the  mis-use  of  the  voice 
demand  the  knowledge,  experience  and  skill  of 
voice  mechanicians  and  voice  trainers. 

"The  student  whose  voice  has  been  injured, 
either  by  mal-treatment  of  a  charlatan,  or  un- 
hygienic habits  of  living,  must  not  attempt  to 
cure  himself,  nor  should  he  go  to  any  but  a 
teacher  whose  skill  is  unquestionable,  for  the 
slightest  imperfection  in  the  cure  may  ruin  the 
voice  permanently."     (Mme.  Cappiani.) 

I  wish  to  mention  a  peculiar  mechanical  condi- 
tion which  I  have  sometimes  observed. 

If  a  bolus  of  food,  in  its  passage  through  the 
pharynx,  receive  any  impetus  at  all  from  pres- 
sure of  the  f  aucial  tonsil,  then  enucleation  of  the 


302  THE    TONSILS    AND    THE    VOICE 

tonsil  plus  the  contraction  of  tissue  due  to  cicatri- 
zation may  interfere  with  the  act  of  swallowing. 
Especially  in  elderly  persons,  in  whom  the  act  of 
swallowing  is  sometimes  tedious,  appearing  like 
a  condition  almost  of  semi-paralysis,  we  may 
find  an  aggravated  condition  owing  to  enuclea- 
tion at  some  previous  time.  These  cases  of  slow 
process  in  swallowing  are  not  so  uncommon  in 
old  people. 

In  a  case  of  this  kind,  slightly  magnified  by  an 
acute  swelling  of  the  lingual  tonsil,  the  attending 
physician  made  the  diagnosis  of  "paralysis  of 
the  vocal  cords,"  and  "advised  an  immediate 
tracheotomy."  I  was  then  called  into  consulta- 
tion; changed  the  diagnosis;  and  we  promptly 
cured  the  patient  of  his  lingual  tonsillitis. 

Escat  (Technique  Oto-Rliino-Laryngologi- 
que,  1911)  says:  "The  various  symptoms  of 
isolated  troubles  in  professional  singers  are  quite 
varied :  the  greater  part  are  impossible  to  classify, 
by  reason  not  only  of  the  difficulty  of  penetrating 
their  mechanism,  but  even  to  define  them,  for 
empiricism,  in  spite  of  the  very  earnest  researches 
of  which  vocal  physiology  has  been  the  subject, 
reigns  still  as  master  in  this  pathology  of  singing : 
the  bond  of  union  still  remains  to  be  found  be- 
tween these  two  sciences,  which  have  refused  so 
far  to  permit  themselves  to  be  penetrated." 

Hyperplastic. 

To  enable  one  to  draw  the  differential  lines  of 
diagnosis  in  the  scientific  differentiation  of  ton- 
sillar enlargement,  it  becomes  a  sine  qui  nan  that 


DIAGNOSIS  303 

we  must  accept  a  clear  definition  of  what  consti- 
tutes a  normal  tonsil. 

The  microscope  will  show  the  actual  histologic 
structure  of  the  tonsil.  Having  a  normal  histo- 
logic constitution,  the  relative  size  of  the  organ 
then  comes  into  question :  a  large  tonsil  in  a  large 
mouth  is  normal :  whether  it  is  out  of  proportion 
depends  upon  whether  it  presses  unduly  upon 
neighboring  tissues,  or  protrudes  into  the  lumen 
of  the  fauces  so  as  to  interfere  with  deglutition 
or  phonation,  or  with  both.  The  organ  may  be 
histologically  normal,  and  yet  he  too  small  to 
properly  perform  its  mechanical  function  in  sing- 
ing and  speaking. 

Having  a  normal  structure,  it  is  necessary  to 
determine  with  great  care  whether  the  enlarge- 
ment is  temporary  or  permanent.  Temporary 
being  due  to  some  transient  cause,  as  for  example, 
an  acute  coryza,  or  a  mis-use  of  the  voice,  giving 
rise  to  momentary  increased  functional  or  cellular 
demand — mere  swelling,  or  simple  enlargement. 

Continued  coryza,  or  continued  abuse  of  the 
voice  mechanism,  will  more  permanently  increase 
the  size  of  the  cellular  structure,  by  reason  of  a 
sustained  demand  on  functional  action — the 
organ  thus  becomes  simply  hypertrophied — cells 
are  enlarged.  Simple  hypertrophy  is  enlarge- 
ment of  normal  specific  structural  elements,  due 
to  increased  functional  activity. 

Increase  in  size  of  the  structural  cells  is  hyper- 
trophy: increase  in  their  number  is  hyperplasia. 
The  same  tonsil  may  be  both  hypertrophic  and 
hyperplastic. 


30 1  THE    TONSILS    AND   THE    VOICE 

Hyperplasia  of  the  tonsil  is  more  often  scrof- 
ulous than  tubercular. 

Sarcoma,  carcinoma,  and  other  forms  of  en- 
largement are  to  be  diagnosticated  by  the  micro- 
scope. 

Many  years  in  the  practice  of  my  profession 
have  taught  me  to  respect  the  opinions  of  others, 
the  opinions  of  younger  men,  and  particularly 
the  opinions  of  those  who  are  older  and  more  ex- 
perienced than  myself.  Knowledge  is  ripened  by 
experience.  Henry  Clay  "depended  on  nothing 
else  so  much  as  on  experience."  Madame  Bern- 
hardt with  advancing  years  has  materially 
changed  her  interpretation,  softened  the  char- 
acter and  made  more  etherial  her  impersonation, 
of  the  unfortunate  Camille, 

The  very  highest  value  is  to  be  placed  upon 
the  knowledge  obtained  from  the  practical  ac- 
quaintance of  the  many  years  of  personal  expe- 
rience and  repeated  observations  of  authorities 
like  A.  Jacohi,  Casteoc,  La7nperti  and  Mme.  Cap- 
piani.  They  know  the  pastj  and  they  look  into  the 
future. 

"In  fearless  youth  we  tempt  the  heights  of  arts; 
While  from  the  bounded  level  of  our  mind, 
Short  views  we  take,  nor  see  the  lengths  behind; 
But  more,  advanced,  behold  with  strange  surprise 
New  distant  scenes  of  endless  science  rise!" 
"Modern  'pothecaries,  taught  the  art 
By  doctors'  bills  to  play  the  doctor's  part, 
Bold  in  the  practice  of  mistaken  rules. 
Prescribe,  apply,  and  call  their  masters  fools." 
(Pope's  Essay  on  Criticism.) 


DIAGNOSIS  305 

There  are  many  diseases  of  the  faucial  tonsil 
and  many  appropriate  lines  of  treatment. 

To  cure  the  various  diseases,  and  to  preserve 
the  important  functions  of  this  valuable  organ, 
require  the  most  accurate  scientific  discrimina- 
tion between  affections  that  are  primary,  second- 
ary, symptomatic,  reflex,  mechanical,  and  hyper- 
plastic. Every  case  is  important:  valuable  func- 
tions are  involved.  Every  case  must  be  scientif- 
ically differentiated;  or  the  attendant  may  pos- 
sibly be  charged  icith  ignorance  and  crime. 


21 


CHAPTER  XII 

HYGIENE  OF  THE  FAUCIAL  TONSIL: 
HYGIENE  OF  THE  VOICE. 

The  hygiene  of  the  tonsil,  the  preservation  of 
the  health  of  the  organ,  will  be  safeguarded  by- 
observing  the  various  sources  of  trouble,  and  by 
the  establishment  of  rules  or  principles  of  hygiene 
that  will  tend  to  sj^stematize  the  knowledge  of  the 
different  sources. 

The  chief  sources  of  trouble  arise  in  the  mouth, 
nose,  general  system,  nervous  system,  and  from 
mechanical  causes. 

To  protect  the  tonsil  from  disease  in  the 
^outh,  the  buccal  secretions,  as  well  as  those  of 
the  f ossulae  or  crypts  of  the  tonsil,  must  be  kept 
free  as  possible  from  inhaled  dust  containing 
micro-organisms  and  other  noxious  material,  ad- 
mixed with  particles  of  decomposing  food  some- 
times found  about  the  teeth  and  gums,  which 
irritate  and  inflame  the  free  surface  of  the 
mucous  membrane  which  covers  the  tonsil  and 
also  acts  as  a  lining  of  the  fossulae.  The  teeth 
and  gums  must  be  kept  in  good  condition. 

When  necessar}^  the  fossulae  should  be  drained 
and  aero-suction  applied,  or  aero-electrotomy,  to 
strengthen  and  make  more  resistant  to  irritation 
the  lining  of  the  fossulae  and  the  covering  mem- 
brane of  the  tonsil. 

Dust,  germs,  decomposing  food,  and  other 
noxious  material,  affect  the  surface  of  the  tonsil, 
and  the  surface  of  the  lining  of  the  fossulae. 

306 


Vertical  section  of  nose,  pharynx  and  larynx. 

Showing    especially    the   location  of  the  dust-traps. 


I.  Cavities  in  the  bones  of  the  head.  2.  The  nasal  passages.  3.  Orifice  of 
Eustachian  Tube  leading  to  ear.  4.  Uvula.  5.  Pillars  of  the  fauces  with  the 
tonsil  between  them.  6.     Epiglottis.  7.     Thyroid  cartilage.      '     8.     Cricoid 

cartilage.  9.      Ventricle    of    larynx.  10.       Vocal    cord.  11.       Trachea. 

12.     ELsophagus.  13.     Front    dust-trap     (nasal    vestibule).  14.      Rear   dust- 

trap   (post-nares). 


HYGIENE    OF    THE    FAUCI-AL    TONSIL  307 

To  protect  the  tonsil  from  infection  from  the 
nosCj  by  morbid  material  carried  by  the  lym- 
phatic vessels  from  the  nose  to  the  inside  of  the 
tonsil,  in  the  manner  as  proved  by  Von  Lendrt, 
and  accepted  by  Frdnkel,  Von  Levinstein,  Jaco- 
hi,  and  others,  the  nasal  passages  should  he  kept 
absolutely  clean  and  constantly  sterilized. 

The  effect  of  the  transmission  of  noxious  ma- 
terial from  the  nose  to  the  inside  of  the  tonsil  is 
to  render  the  organ  tender,  painful  and  swollen — 
it  seldom  causes  inflammation  or  suppuration. 

The  nose  is  a  much  abused  and  greatly  ne- 
glected organ.  Persons  of  intelligence  and  refine- 
ment, fastidious  in  taste,  and  immaculate  in  dress, 
are,  nevertheless,  ignorant  of  the  transcendent 
importance  of  the  necessity  of  a  toilet  of  the 
nose,  a  subject  on  which  no  treatise  has  yet  ap- 
peared. 

The  nose  is  the  commencement  of  the  respira- 
tory tract.  The  air  we  breathe  should  enter 
through  the  nose,  not  through  the  mouth.  It  is 
warmed  and  moistened  in  the  nasal  passages. 
The  volume  of  air  required  daily  for  each  person, 
in  ordinary  natural  respiration,  is  10,000  litres. 
Thirty  cubic  inches  of  air  are  inhaled  with  every 
ordinary  inspiration;  there  are  eighteen  respira- 
tions every  minute,  and  1,080  respirations  every 
hour;  540  cubic  inches  of  air  are  inhaled  every 
minute,  and  32,400  cubic  inches  every  hour.  And 
all  this  goes,  or  should  go,  in  through  the  nose. 

Air  carries  into  the  nose  many  impurities — 
dust,  smoke,  germs  and  other  noxious  material. 
Germs  are  floating  in  the  air,  everywhere,  in 
large  quantities.   Whenever  dust  is  raised,  in  the 


308  THE    TONSILS    AND    THjE    VOICE 

street,  in  factories,  in  schools,  in  hospitals  and  in 
other  places,  we  inhale  with  the  cloud  a  large 
number  of  microbes. 

It  is  stated  by  Von  Schrotter  (Hygiene  of  the 
Lung)  that  "In  the  parks  of  Berlin^  fhe  air  con- 
tains always  from  100  to  1,000  germs  per  cubic 
metre.  There  are  as  many  as  800  per  cubic  metre 
on  top  of  the  tower  of  the  Rathaus,  while  the  air 
of  an  inhabited  room  contains  from  6,000  to  10,- 
000  per  cubic  metre." 

"In  one  gramme  of  dust  from  the  floor-cover- 
ing of  one  of  our  chief  public  institutes,  6,600,- 
000  to  21,000,000  bacteria  were  estimated  in  a 
scientific  investigation." 

Dust  is  collected  in  the  vestibule  of  the  nose 
as  in  a  trap,  and  the  deflection  of  the  current  of 
air  in  the  back  of  the  nose,  at  the  sharp  angle  of 
the  fauces,  acts  as  another  dust-trap. 

It  is  now  apparent  that  the  nasal  passages 
should  be  kept  open  and  clean. 

The  nasal  vestibule  being  the  port  of  entry  de- 
mands scrupulous  attention;  it  should  be  zealous- 
ly guarded  against  the  invasion  of  dust  and 
germs.  Protection  of  the  vestibule  will  prevent 
penetration  of  the  deeper  passages.  Nothing 
must  be  permitted  to  go  beyond  the  vestibule. 
Accumulations  should  be  carefully  and  gently 
mopped  out,  not  washed  far^ther  in  by  sprays  or 
douches.   Don't  spray.   Dont  douche. 

The  nasal  vestibule  should  be  gently  and  thor- 
oughly mopped  morning  and  evening  as  a  fln- 
ishing  touch  to  the  toilet,  with  a  wad  of  absorbent 
cotton  saturated  with  a  solution  of  powdered 


HYGIENE    OF    THE    FAUCIAL    TONSU.  309 

borax,  68  grains,  warm  water,  one  pint,  and  es- 
sence of  peppermint,  20  minims. 

Don't  pluck  the  hair  from  the  nose.  It  pre- 
vents the  entrance  of  dust.  Never  blow  the  nose 
violently.  Whenever  the  nasal  passages  are  con- 
gested or  uncomfortable  from  an  acute  cold,  ap- 
ply heat  to  the  bridge  of  the  nose  by  a  sponge  or 
towel  wrung  out  of  hot  water,  or  by  a  thermic 
electric  ray. 

To  protect  the  tonsil  from  trouble  arising  from 
the  general  system^  constitutional  treatment  is 
required. 

To  protect  the  tonsil  from  affections  of  the 
nervous  system,  occurring  as  a  matter  of  reflex, 
the  original  trouble  must  be  sought  for  and 
abated. 

In  recurrent  tonsillar  trouble,  from  any  cause, 
the  general  system  should  be  hardened  by  sys- 
tematic exercises,  fresh  air,  habits  of  cleanliness, 
wholesome  food,  good  digestion,  regulated 
bowels,  ventilated  and  sanitary  sleeping  apart- 
ments, proper  sleeping  hours,  etc. 


310  THE    TONSILS    AND    THE    VOICE 

HYGIENE  OF  THE  VOICE. 

D.  Ffrangcon-Davies  in  his  admirable  work 
(The  Singing  of  the  Future)  says: 

"A  purely  scientific  or  a  mathematical  brain 
would  not  make  much  of  the  singer's  art.  The 
whole  spiritual  system,  spirit,  mind,  sense — soul, 
together  with  the  whole  muscular  system  from 
feet  to  head,  will  be  in  the  wise  man's  singing, 
and  the  whole  man  will  be  in  the  tone." 

Frank  E.  Miller  says:  "It  is  more  difficult  to 
keep  the  keen  edge  of  the  voice  in  good  repair 
than  that  of  the  sharpest  razor.  No  one  more 
than  the  singer  requires  to  observe  the  moral  and 
physical  laws," 

Inquiry  among  the  greatest  artists  has  elicited 
the  fact  that  they  are  scrupulously  careful  of 
their  health. 

3Iadame  Adelina  Patti,  now  the  Baroness 
Cedarstrom,  in  a  personal  communication  to  the 
author,  has  stated  that 

"I  have  never  had  any  trouble  with  my  throat 
or  voice  during  my  entire  career  as  a  vocal  ar- 
tiste." 

Madame  Nordica  communicated  to  me  the 
statement  that 

"I  have  never  had  my  throat  touched,  or 
sprayed,  in  my  life." 

Madame  Homer,  in  her  personal  communica- 
tion, said: 

"I  remember  with  pleasure  your  kind  and  most 
helpful  treatment.  I  have  never  heard  of  a  sing- 
er who  had  their  tonsils  removed.  I  have  the 
greatest  prejudice  against  it." 


HYGIENE    OF    THE    VOICE  311 

Miss  Cecelia  Winter  told  me  that 

"It  is  a  well-known  fact  among  singers  that 
those  voices  are  strongest  and  best  where  the 
throat  has  not  been  tampered  with  by  surgeons." 

Many  young  voices  are  ruined  for  want  of 
care, 

Casteoc,  one  of  the  greatest  authorities  on  the 
maladies  of  the  voice  and  voice  hygiene,  in  his 
work  entitled  ''Hygiene  de  la  Voix  Parlee  et 
Chantee/'  states: 

"The  singing  and  speaking  voices  differ  from 
each  other  in  three  principal  qualities  of  sound. 
The  compass  is  smaller  in  the  speaking  voice,  the 
intensity  is  less,  and  the  timbre  greatly  different." 

"Actors  have  found  it  well  to  learn  to  sing,  in 
order  to  make  the  voice  carry  and  last.  Gai'cia 
several  times  had  occasion  to  give  lessons  in  sing- 
ing to  military  officers,  who  wished  to  have  their 
voices  carry  well  when  issuing  commands,  with- 
out causing  fatigue." 

"In  a  general  way,  speech  fatigues  the  phon- 
ator  organs  more  than  does  singing." 

"A  voice  in  its  decline  finds  itself  more  at  ease 
in  tragedy  than  in  comedy  roles,  which  exact  a 
much  greater  flexibility." 

"In  a  general  way  to  conserve  the  voice,  it 
should  be  kept  in  the  medium  tones  of  the  organ." 

"A  methodical  and  rational  elocution  is  the  best 
guarantee  against  the  various  affections  which 
may  attack  the  vocal  apparatus  of  an  orator." 

"Granular  pharyngitis  is  more  frequent  in 
preachers  and  lawyers,  who  are  more  pre-occu- 
pied  with  the  substance  than  with  the  form,  than 


312  THE    TONSILS    AND    THE    VOICE 

among  actors  closely  attached  to  the  form  of  the 
elocution." 

"To  put  himself  in  proper  form  the  orator 
should  apply  himself  to  various  exercises  as  fol- 
lows: 

"(1)  Extend  his  voice  in  the  low  as  well  as 
the  high  registers." 

"(2)  Emitting  clearly,  one  after  the  other, 
each  note  of  his  vocal  compass  in  working  succes- 
sively on  each  vowel,  then  associating  consonants 
with  vowels,  for  the  clearness  of  the  articulation 
of  the  consonants  will  supplement  the  insuffi- 
ciency of  the  voice." 

"(3)  Establish  his  habitual  voice  at  a  height, 
a  medium  diapason,  an  intensity  and  a  medium 
on  which  he  can  speak  without  fatigue.  He 
should  exercise  each  day." 

"(4)  Exercise  making  sudden  variations  of 
tone.  Nothing  is  more  useful  in  arresting  the 
attention  of  the  hearer." 

"  (5)  Study  the  times  and  the  modes  of  respir- 
ation." 

"(6)  Attack  clearly  the  sound  by  a  stroke  of 
the  glottis." 

"  (7)  Do  not  lose  breath  before  the  emission  of 
the  sound." 

"(8)  Exercises  in  agility  are  good  for  the 
speaker." 

"(9)  To  'place'  his  voice  at  the  level  of  his 
lips." 

"(10)  Make  his  voice  resound  at  its  best,  in 
well  disposing  the  resonators." 

"(11)  It  is  necessary  to  'complete,  equalize, 
and  tune  the  instrument':  to  lead  it  successively 


HYGIENE    OF    THE    VOICE  313 

in  the  various  registers,  to  arrive  at  that  variety 
of  timbre  which  is  at  once  a  charm  for  the  auditor 
and  a  repose  for  the  reader." 

"(12)  Habituate  himself  to  proportion  his 
voice  to  the  locahty  in  which  he  speaks,  to  the 
end  that  his  voice  may  'carry'  at  its  best  in  the 
various  places.  Singing  lessons  are  very  useful 
to  the  orator,  as  lessons  in  diction  are  to  the  sing- 
er. There  is  here  a  supplementary  education 
which  is  not  to  be  despised  by  either.  Finally,  if 
the  orator  wishes  to  use  his  voice  at  its  best,  he 
should  know  how  to  write  for  the  voice,  that  is  to 
say,  how  to  compose  his  discourses  in  short  and 
sonorous  phrases.  The  orator  should  watch  over 
his  general  health,  and  that  of  his  lungs,  bronchi, 
trachea,  larynx,  pharynx,  mouth  and  nose." 

"He  must  exercise  then  in  a  rational  way.  He 
must  have  a  good  technic." 

"if  he  shouts,  his  voice  will  not  carry. 
He  should  speak  slowly  at  the  start." 

"If  an  orator  is  compelled  to  begin  speaking 
when  his  voice  is  veiled,  then  let  him  begin  just 
as  it  is,  without  trying  to  clear  it  by  coughing  or 
forcing  it.  'Start  from  where  you  are.'  Little 
by  little,  the  voice  will  warm  up,  and  if  it  does 
not  become  entirely  clear,  at  least  it  has  not  be- 
come extinct.  Even  a  hoarseness  may  disappear 
on  condition  of  having  commenced  'piano.' 

"The  antique  mask  of  the  tragedians  and  come- 
dians seemed  to  have  had,  among  other  usages, 
that  of  reinforcing  the  voice  by  means  of  a  resr 
onating  plaque  of  some  kind." 

"The  singing  voice  has  its  own  conditions  very 


314  THE   TONSILS   AND   THE   VOICE 

distinct  from  those  which  we  have  recognized  in 
the  speaking  voice." 

"The  singer  should  take  care  to  breathe  well, 
fully  but  silently." 

"For  the  proper  conservation  of  the  voice,  it 
is  important  not  to  overwork  it  and  to  manage  it 
with  ease  and  without  violence,  especially  when 
the  artist  finds  himself  charged  with  a  heavy  vo- 
cal service." 

''These  precautions  assure  the  conservation  of 
a  voice,  not  only  during  the  evening  hut  as  ti-ell 
during  an  entire  artistic  career'' 

"All  pure  exercises  of  art  must  conform  to 
physiology.  Every  defective  method  brings  on 
a  harmful  congestion  of  the  larynx." 

"The  voice  runs  great  danger  in  being  used 
when  hoarse.  Nothing  is  more  pernicious  than  to 
sing  with  a  cold." 

"A  particularly  fatiguing  thing  to  artists  is 
the  necessity  of  singing,  alternately,  roles  of  dif- 
ferent pitch." 

"We  should  conserve  especially  those  voices 
which  are  naturally  beautiful.  They  are  more 
fragile  than  voices  somewhat  manufactured." 

"The  face  and  all  the  exterior  of  the  singer, 
should  not  betray  the  effort;  no  grimaces,  no 
wrinkling  of  the  forehead,  no  swelling  of  the 
veins  of  the  neck.  Exterior  constraint  leads  to 
troublesome  contraction  of  the  internal  organs. 
It  is  necessary  to  sing  calmly." 

"When  singing  becomes  painful  and  is  ac- 
companied with  a  sensation  of  local  fatigue,  of 
embarrassing  tension,  of  spasm,  it  is  necessary  to 
stop.  It  is  singer's  cramp  which  is  announcing  it- 


HYGIENE    OF    THE    VOICE  315 

self.  It  occurs  particularly  when  one  has  sung 
a  piece  which  is  too  high,  with  too  great  a  range 
for  the  natural  compass  of  the  voice." 

"The  duration  of  voice  exercise  is  of  great  im- 
portance. To  avoid  tiring  the  voice,  the  exercise 
should  be  limited  to  one  hour  of  work  a  day,  di- 
vided into  four  periods  of  a  quarter  of  an  hour 
each.  And  rests  should  be  taken  in  these  quarter 
hour  periods." 

"Fatigue,  or  professional  affections  of  the 
pharynx,  sometimes  determine  an  alteration  of 
the  timbre,  which  is  erroneously  sought  for  in 
the  larynx." 

"Artists  should  make  sure  of  one  or  two 
months'  vacation  each  year,  during  which  they 
should  leave  their  voices  in  almost  complete  re- 
pose. This  is  also  a  good  method  to  assure  the 
duration  of  the  voice." 

"Artists  should  consider  the  capabilities  of  the 
human  larynx,  and  avoid  compositions  not  suit- 
able for  the  voice." 

"After  having  acquired  its  development,  the 
voice  has  need  of  regular  exercise.  Sing  with 
medium  force.     Avoid  'bawling'." 

"The  happy  effect  of  training  upon  the  voice 
is  appreciable,  even  in  the  course  of  a  single  day. 
Singers  have  made  the  remark  that  the  voice  of 
the  'morning'  is  fresh,  but  hard,  and  that  the 
voice  of  the  'evening'  on  the  contrary,  though  less 
clear,  can  be  used  for  a  longer  time  without  fa- 
tigue." 

"Above  all,  the  singer  should  care  for  his  gen- 
eral health,  for  the  various  states  of  this  react  ac- 


316  1HE    TONSILS    AND    THE    VOICE 

cording  to  their  nature,  in  good  or  harm  for  the 
voice." 

"Little  or  no  alcohol,  nor  dishes  irritating  to 
the  throat  (mustard,  cayenne  pepper,  etc.).  A 
complete  toilet  of  the  vocal  apparatus  is  called  for 
every  morning." 

"These  cares  are  a  natural  preparation  for  that 
other  toilet  that  Faure  justly  calls  the  'toilet  of 
the  voice.'  By  this  is  meant,  the  morning  exercises. 
Thanks  to  these  various  habits  the  singer  will 
no  longer  be  exposed  to  the  inconvenience  of  hav- 
ing his  voice  'dirty,'  following  the  ordinary  com- 
parison." 

"A  mischievous  habit  is  that  of  coughing  be- 
fore singing.  This  easily  causes  hoarseness  and 
congestion." 

"On  the  day  of  a  performance  the  artist  should 
avoid  any  particular  fatigue  of  his  larynx,  and 
the  general  fatigue  of  his  body;  no  fencing,  no 
riding.  Some  even  have  the  habit  of  going  to 
bed  a  portion  of  the  day.  Women  should  spare 
their  voices  for  two  or  three  days  at  particular 
times  of  the  month." 

"Hygiene  for  singers  is  strict,  who,  to  speak 
truly,  are  the  subjects  of  an  extremely  sensitive 
organ." 

"Do  there  exist  certain  recipes  for  putting  the 
singer  in  voice?  Some  authors  attach  to  this  a 
certain  importance." 

"To-day  when  vocal  hygiene  tends  to  become 
more  exacting  and  scientific,  one  cannot  accord 
any  particular  virtue  to  the  various  recipes  and  I 
make  no  decision.  It  is  for  each  one  to  use  what 
his  own  experience  shall  have  designated  to  him 


HYGIENE    OF    THE    VOICE  317 

as  preferable.  There  are  no  rules  to  be  estab- 
lished in  that." 

Casteoc  (Maladies  de  la  Voice,  1902) : 

"Maladies  of  the  voice,  and  maladies  of  the 
larynx  are  very  different  things,  since  a  vocal 
trouble  may  have  its  cause  in  the  nasal  fossae  or 
in  the  lungs,  or  even  in  the  general  health,  while 
the  larynx  remains  immune.  If  it  relates,  on  the 
contrary,  to  a  veritable  affection  of  the  larynx, 
as  cancer  or  tuberculosis,  the  question  of  voice 
then  becomes  negligible.  An  excellent  voice  may 
be  up  to  par  with  the  larynx  in  bad  condition. 
I  have  seen  the  cords  thickened,  red,  presenting, 
in  fact,  all  the  symptoms  of  corditis,  in  artists  in 
whom  the  voice  gave  no  trouble.  Krause 
(Berlin)  and  others  have  made  the  same  obser- 
vation. This  distinguished  professor  is  said  to 
have  treated  a  young  tenor  in  whom  the  cords 
were  transformed  into  two  red  fleshy  cushions. 
The  voice  was  soft  and  agreeable." 

"It  is  the  diagnosis  of  a  malady  of  the  voice, 
which  is  difficult." 

"A  rational  method  in  singing,  as  in  speaking, 
counts  for  much  in  the  preservation  of  the  vocal 
apparatus." 

"It  happens  at  times  that  a  vocal  trouble 
shows  itself  in  the  singing  long  before  it  appears 
in  the  speech." 

"Alcohol  is  very  damaging  to  the  voice.  It 
causes  a  constant  congestion  in  the  pharynx  and 
the  larynx,  which  finally  results  in  chronic  phar- 
yngo-laryngitis.  I  have  had  voices  lost  by  the 
use  of  alcohol." 

Coffee,  grog,  punch,  or  champagne,  give  only 


318  THE    TONSILS    AND    THE    VOICE 

a  transitory  energy,  soon  followed  by  a  vocal  de- 
pression." 

"Fatty  aliments  are  favorable.  On  the  whole, 
a  mixed  diet,  animal  and  vegetable,  agrees  the 
best." 

"Three  hours  should  elapse  as  a  medium  be- 
tween the  repast  and  the  exercise  of  singing." 

"The  artist  should  guard  against  dyspepsia. 
One  may  sing,  having  a  great  number  of  mala- 
dies, but  it  is  no  longer  possible  with  an  affection 
of  the  stomach,  which  interferes  with  the  play  of 
the  diaphragm,  and  depresses  the  ensemble  of 
the  forceis.     Keep  the  mouth  and  teeth  healthy." 

"The  entire  nervous  system,  the  brain  above 
all,  has  an  influence  on  the  voice.  Passions  de- 
press it.  Emotions  of  gaiety,  joy,  render  it 
facile.  To  quote  Mandl,  'The  voice  is  the  mir- 
ror of  the  soul.'  " 

"Smoking  tobacco  is  detrimental  to  the  voice. 
Cigarettes  are  particularly  damaging,  producing 
hoarseness.  Especially  bad  for  tenors  and  for 
those  who  begin  to  feel  the  first  disabilities  of 
age." 

"Wear  wool.  No  tight  corsets.  Don't  wear 
neck  wrappings.    Dust  and  smoke  are  bad." 

''Vocal  nodules.  They  arise  from  vocal  ex- 
cesses, overwork  or  bad  management  of  the  voice. 
They  may  develop  rapidly,  or  insidiously." 

"Treatment  consists  in  complete  vocal  repose 
for  several  weeks.  The  nodules  may  disappear 
by  this  means  alone.  Avoid  forcing  of  the  tones : 
Keej)  the  voice  in  the  middle  register,  and  do  not 
allow  it  to  wander  into  the  high :  change  teachers 
if  there  is  reason  to  do  so." 


HYGIENE    OF    THE    VOICE  319 

"As  a  general  rule,  one  must  be  exceedingly 
cautious  in  operations  on  the  larynx  of  artists, 
for  vocal  repose  and  less  offensive  means  often 
suffice  to  put  them  in  good  order." 

"Resume.  The  physical  alterations  of  the 
structures  of  the  larynx,  united  under  the  term 
laryngitis,  whether  they  proceed  from  a  veritable 
malady,  or  from  fatigue,  generally  attack  the 
timhre" 

"The  abuse  of  speech,  ill  advised  enthusiasms, 
or  a  too  rapid  education,  compromise  chiefly  the 
solidity" 

"Vocal  excesses,  or  exaggerated  efforts  may 
diminish  the  compass." 

"In  trouble  in  the  agility,  a  latent  laryngeal 
tuberculosis  may  be  suspected." 

"If  the  medium  is  affected,  look  first  to  the 
chest  (pulmonary  bellows)." 

"Troubles  of  clearness  (cats,  graillons, 
phlegm,  etc. )  coincide  ordinarily  with  a  catarrhal 
state  of  the  chief  respiratory  passages." 

"Troubles  of  resonance  are  almost  always  of 
nasal  origin." 

"When  the  intensity  weakens,  search  at  first 
for  the  cause  in  a  weakening  somewhere,  of  the 
general  condition." 

"For  nervous  troubles,  it  goes  without  saying, 
that  they  arise  from  the  neuropathic  tempera- 
ment of  the  subject." 

"This  parallel  has  served  me  often.  It  is  why 
I  reproduce  it  here,  not  without  saying  that  a  de- 
tailed investigation  for  each  patient,  is  the  neces- 
sary complement." 

Garcia  {Hints  on  Singing)  asks  the  question: 


320  THE    TONSILS    AND    THE    VOICE 

"To  what  would  you  ascribe  the  fatigue  of  the 
vocal  organs?" 

"Answer.  Besides  the  different  ailments  of  the 
vocal  organs,  which  concern  the  physician, 
there  are  other  causes,  such  as  misdirected  study 
or  overwork." 

"Question.  Are  there  any  other  symptoms?" 

"Answer.  Hoarseness,  relaxed  throat,  languor 
of  the  organ,  which  refuses  to  execute  passages 
generally  possible ;  dryness  or  heat  in  the  throat, 
difficulty  in  swallowing,  fatigue  after  a  few  min- 
utes exercise." 

Mme.  Cappiani  (Practical  Hints  and  Helps 
for  Perfection  in  Singing)  says: 

"An  earnest  student  adopts  a  sensible,  sys- 
tematic plan  of  living  and  studying  in  order  to 
obtain  the  best  results.    I  would  suggest: 

"(1)  A  moral  life,  plenty  of  sleep  and  fresh 
air." 

"(2)  Eating  at  regular  hours,  food  that  is 
easily  digested." 

"(3)   Avoid  alcoholic  drinks." 

"(4)  Hearing  concerts  and  operas  during  the 
daytime  when  possible,  in  order  to  avoid  late 
hours." 

"(5)  Between  lessons,  practicing  along  sys- 
tematically, twent}^  minutes  at  a  time,  then  tak- 
ing a  half  hour's  rest  which  can  be  employed  to 
advantage  in  doing  other  work,  such  as :  studying 
languages,  pianoforte,  musical  history,  physical 
culture,  dancing,  fencing,  designing,  painting, 
etc." 

"(6)  Wearing  suitable  clothes  for  changes  of 
temperature  to  guard  against  colds." 


HYGIENE    OF    THE    VOICE  321 

"(7)  Avoiding  invitations  that  involve  too 
many  social  duties,  calls,  etc.,  which  waste  time 
better  employed  in  outdoor  exercise." 

"Do  not  be  over  sensitive  in  giving  weight  to 
gossip  about  your  voice  and  skill.  Have  con- 
tempt for  flattery.  Have  patience  in  your  art. 
Be  cheerful.  Have  faith  in  yourself;  be  earnest 
and  diligent,  and  then  with  indomitable  persever- 
ance, you  will  succeed." 

"What  is  good  for  the  general  health  is  good 
for  the  voice.  All  kinds  of  nuts,  because  of  the 
oil  they  contain,  should  be  avoided  on  the  day  of 
a  public  performance." 

"Drinks,  such  as  hot  coffee  and  tea,  or  drinks 
that  are  too  cold,  taken  just  before  singing,  are 
injurious." 

"Beware  of  eating  ice  cream  before  singing." 

"No  alcoholic  drinks  whatever  should  be  used 
by  young  singers;  they,  at  best,  being  harmful 
stimulants." 

"On  two  occasions  I  had  pupils,  a  tenor  and  a 
baritone,  who  were  to  sing.  Both  of  them  took 
champagne,  expecting  thereby  to  gain  courage. 
The  result  was  a  rush  of  blood  to  the  throat  and 
neither  was  able  to  sing." 

"For  experienced  singers,  advanced  in  age, 
or  for  singers  of  anaemic  constitution,  half  a 
glass  of  good,  pure  claret  is  serviceable  as  a  stim- 
ulant." 

"For  further  information  on  diet,  I  would  ad- 
vise all  singers  to  take  the  counsel  of  a  compe- 
tent physician." 

''Important  Suggestions : 

.22 


322  '^HE    TONSILS    AND    THE    VOICE 

"Singing  in  open  air  is  permissible  only  in  a 
calm  atmosphere." 

"Singing  or  speaking  in  a  carriage  or  in  a 
rapidly  moving  train  is  very  bad." 

"To  preserve  his  voice,  a  singer  should  never 
scream,  laugh  or  speak  unnecessarily  loud." 

"Stiff  collars  and  tight  ribbons,  act  like  tight 
corsets  on  the  throat  and  are  dangerous  fashions 
for  the  general  health." 

"Wearing  corsets,  so  loose  that  one  can  put 
them  on  as  they  are  taken  off  is  rather  an  advan- 
tage as  they  protect  the  spine.  A  singer  must 
be  provided  with  corsets  that  allow  the  lowest  ribs 
to  expand." 

"Those  who  cannot  abstain  from  smoking 
should  exercise  in  moderation  and  should  never 
inhale  the  smoke.  Swallowing  the  smoke  and  let- 
ting it  out  through  the  nostrils  is  very  injurious." 

Mme.  Patti,  whose  marvelous  voice  was  mar- 
velously  preserved,  says: 

"Dieting  for  the  sake  of  the  voice  is  nonsense. 
There  must  be  moderation,  of  course,  in  all  things, 
for  the  singer,  above  all  other  persons,  must  study 
intelligent!}^  her  individual  health  conditions.  She 
must  learn  how  to  keep  herself  well.  The  girl 
who  is  ambitious  to  sing  need  not  deny  herself 
anything  she  fancies  at  the  table  unless  that  par- 
ticular thing  happens  to  disagree  with  her,  un- 
less, indeed,  she  is  to  appear  on  the  stage  that 
same  day.  On  the  day  of  public  performance  it 
is  necessary  to  eat  very  little." 

"Soup  is  really  the  best  food  for  singers,  strong 
soup,  well  made.  Rare  beef  is  good,  fruit  and 
vegetables.     Pastry  and  sweets  are  not  good, 


HYGIENE    OF    THE    VOICE  323 

but  are  to  be  avoided  more  because  they  hurt 
the  complexion  than  because  they  affect  the  voice 
especially." 

"What  wines  may  a  young  singer  allow  her- 
self?" 

"If  she  really  means  to  succeed,  no  wines  at 
all.  I  don't  believe  in  wine.  It  hurts  the  throat 
almost  invariably.  Some  young  singers,  I  know, 
are  not  strong,  and  doctors  prescribe  claret  for 
them,  but  it  is  bad  practice  to  drink  it.  For  my- 
self, I  never  drink  wine.  I  drink  water,  or,  if  I 
need  a  stimulant,  I  take  water  with  a  little  whisky 
in  it." 

"If  you  were  interested  in  a  girl  with  a  voice, 
would  you  have  her  go  in  for  athletics  to  build 
herself  up  physically?" 

"That  would  be  ruinous  policy.  The  girl  who 
is  going  to  rank  as  a  singer  must  keep  out  of  the 
gymnasium.  She  can't  fence.  She  can't  row. 
She  can't  ride  horseback.  I  enjoy  nothing  more 
than  horseback  riding,  and  I  ride  well.  I  used 
to  ride  about  Mount  Vernon  when  I  was  only 
six  years  old.  But  I  have  given  up  all  that  en- 
tirely. I  never  ride  now.  It  interfered  with  the 
firmness  and  evenness  of  the  voice  and  gives  a 
tremolo." 

"Walking  is  the  singer's  exercise.  The  singer 
who  has  a  good  pair  of  legs  must  think  herself 
highly  fortunate.  I  can  walk  three  or  four  hours 
at  a  good  pace  and  I  do  so  frequently.  I  believe 
in  regular  exercise,  and  the  best  way  to  take  it  is 
to  drive,  then  leave  the  carriage  for  a  while,  but 
let  it  follow  to  pick  you  up  if  you  find  yourself 
getting  tired." 


324  THE    TONSILS    AND    THE    VOICE 

"If  I  were  interested  in  a  student  I  would 
urge  her  to  be  careful  as  to  what  sort  of  air  she 
breathes.  It  is  very  necessary  to  give  attention 
to  the  ventilation  of  one's  bedroom.  It  should 
not  have  a  fire  in  it  and  the  air  should  be  fre- 
quently renewed.  She  should  not  associate  too 
closely  with  tobacco  users.  Even  the  fumes  of 
the  weed  are  bad  for  the  throat." 

"How  would  you  dress  a  young  singer?" 
"No  directions  are  necessary  except  the  hint 
that  good  voices  have  been  spoiled  before  now 
by  tight  lacing.  I  believe  in  a  well-made  and 
property-fitted  corset,  but  it  should  not  fit  closely 
enough  to  impede  free  breathing  and  the  proper 
expansion  of  the  chest.  Growing  girls  especially 
should  be  careful  not  to  practice  with  lacings 
tightly  drawn." 

"Everything  is  summed  up  in  the  advice  to 
take  sensible  care  of  one's  self.  The  singer  must 
go  to  bed  early  and  not  allow  herself  to  get  tired. 
She  mustn't  fret.  Weariness  and  woriy  tell  on 
the  voice  terribty.  She  must  have  as  few  outside 
cares  as  possible,  and  concentrate  her  efforts  in 
a  single  direction,  live  for  her  art  and  live  hap- 
pily." 

Mme.  Lehmann  (How  to  Sing)  says: 
"There  are  no  magic  cures  for  the  singer." 
"The  repairing  of  a  voice  requires  the  greatest 
appreciation  and  circumspection  on  the  part  of 
the  teacher." 

"There  are  teachers  and  pupils  who  boast  of 
having  effected  magic  cures  in  a  few  hours  or 
days." 

^"^Of  them  I  give  warning!  and  equally  of  un- 


HYGIENE    OF    THE    VOICE        .  325 

principled  physicians,  who  daub  around  in  the 
larynoj,  hum  it,  cut  it,  and  make  everything  worse 
instead  of  better." 

Sir  Charles  Santley  (The  Art  of  Singing, 
1908) : 

"I  do  not  advocate  smoking;  those  who  find 
themselves  perfectly  well  without,  should  leave 
well  alone;  those  who  find  themselves  perfectly 
well  with  it,  ditto!" 

"Hoarseness  attacked  me  when  there  were 
flowers  in  the  room,  particularly  the  (to  me) 
deadly  gardenia,  stephanotis,  hyacinth,  lily,  etc." 

"I  was  singing  at  a  private  party  one  evening, 
in  which  Gardoni,  the  tenor,  a  soprano,  the  daugh- 
ter of  Varesi,  and  others  were  engaged.  I  left 
home  in  splendid  form,  and  was  in  the  drawing 
room  about  half  an  hour  before  the  concert  com- 
menced. I  began  to  feel  rather  husky.  When  it 
came  my  turn  to  sing  I  almost  collapsed,  for  I 
could  scarcely  produce  a  sound.  Mile.  Varesi 
was  in  the  same  plight.  Gardoni  was  husky  and 
all  the  others  were  more  or  less  incapacitated. 
The  concert  concluded,  I  was  conducted  into  a 
room  literal^  packed  with  'harem  lilies,'  the 
deadly  exhalations  from  which  had  penetrated 
the  drawing  room.  I  got  away  as  soon  as  I  could 
and  had  not  been  out  of  the  house  ten  minutes 
before  my  voice  was  as  clear  and  fresh  as  when 
I  entered  it.  I  have  since  had  many  proofs  that 
my  theory,  as  far  as  my  own  throat  is  concerned, 
is  correct.  I  would  advise  all  singers  to  be  on 
their  guard  against  scented  flowers." 

John  Howard  (Physiology  of  Artistic  Sing- 
ing) : 


326  THE    TONSILS    AND    THE    VOICE 

"Spirituous  liquors  inflame  all  mucous  mem- 
branes and  their  influence  upon  a  tone  is  unmis- 
takable. Malt  liquors  appear  to  be  most  harm- 
ful." 

Miller  {The  Voice)  says: 

"Personal  cleanliness  is  one  of  the  first  requi- 
sites.   Bathing  regular — not  extreme." 

"Singers  should  avoid  beef,  lamb  and  mutton. 
White  meat  of  the  fowl  is  the  best  meat  for  the 
vocalist.  Milk,  eggs,  toasted  bread,  string  beans, 
spinach,  lettuce,  rice  and  barlej'^  are  excellent. 
Fruit  stewed — with  little  sugar.  Ice  cream  is 
bad.  No  harm  in  a  cup  of  coffee,  cocoa,  or  tea, 
for  the  singer  in  good  condition.  Smoking  is  in- 
jurious. Silk  underwear  is  dangerous.  Lisle 
thread  or  flannel  excellent." 

Poyet:  "Walking  is  the  best  exercise.  A  well 
understood  hygiene  concerns  the  totality  of 
the  functions." 

"After  singing  exercises  that  cause  perspira- 
tion, rub  down  with  flannel  and  alcohol  and 
change  clothing.  Alcoholics  absolutely  forhid- 
denr 

"Observe  strictly  general  hygiene.  Smoking 
irritates  the  pharj^nx,  reddens  the  vocal  cords,  and 
may  cause  heart  trouble  harmful  to  singers." 

"Avoid  scented  toilet  powders.  Two  hours' 
work  a  day  in  study  or  singing  is  a  maximum." 

"Studies  in  the  bypaths  of  vocal  hygiene  must 
be  dealt  with  as  they  appear." 

Hesume.  Whatever  contributes  to  the  general 
health  favors  the  health  of  the  tonsil,  and,  also, 
the  best  condition  of  the  voice. 

The  hygiene  of  the  mouth,  nose,  throat,  stom- 


HYGIENE    OF    THE    VOICE  327 

ach  and  bowels  is  favored  by  general  and  spe- 
cial cleanliness,  fresh  air,  well  ventilated  sleep- 
ing apartments,  abundant  sleep,  or  repose,  whole- 
some food,  regular  hours  for  eating,  regularity 
of  the  bowels  and  regular  hours  for  sleeping. 

Walking,  in  moderation,  in  the  open  air,  is  the 
exercise  par  excellence  for  voice  users. 

Alcohol  is  irritating  to  the  mucous  membranes, 
and,  also,  for  other  reasons,  has  no  place,  as  a 
rule,  in  the  general  system  of  hygiene. 

As  a  younger  man  I  felt  more  inclined  to  be 
easy  with  tobacco  users,  but  the  older  I  grow  the 
more  I  see  the  bad  effects  of  tobacco,  and  the  less 
I  am  inclined  to  condone  or  cater  to  the  habit. 

A  clean  nose,  a  clean  mouthy  clean  bowels,  clean 
habits,  are  conducive  to  clean  tonsils  and  a  clean 
voice. 


CHAPTER  XIII 
PRINCIPLES  OF  TREATMENT. 

Professor  John  N.  Mackenzie,  of  Johns  Hop- 
kins University,  in  an  address  on  "The  Massacre 
of  the  Tonsils/"  reported  in  the  Maryland  Medi- 
cal Journal,  June,  1912,  says: 

"Never  in  the  history  of  medicine  has  the  lust 
for  operation  on  the  tonsils  been  as  passionate  as 
it  is  at  the  present  time ;  it  is  a  mania,  a  madness, 
an  obsession." 

Evidently  the  treatment  of  the  tonsil  is  in 
urgent  need  of  revolution. 

Professor  Henry  L.  Swain,  of  Yale  Univer- 
sity, in  an  article  entitled,  ''Are  the  Tonsils  a 
Menace  or  a  Protection?'"  published  in  the  An- 
nals of  Otology,  Rhinology  and  Laryngology, 
September,  1911,  after  referring  to  "the  alluring, 
spectacular,  and  gory  operation  called  tonsillec- 
tomy,"' and  to  "the  practice  in  recent  years  of 
many  operators  all  over  the  country,  of  enuclea- 
ting the  tonsils  as  completely  as  possible,  in  all 
cases,  as  a  routine  procedure,"  states  that  "The 
question  of  relative  size,  healthiness  of  structure, 
or  any  such  matter  is  apparently  never  thought 
of.  Even  in  adults  there  are  other  methods  of 
bringing  about  a  satisfactory^  and  safe  condition 
of  the  tonsils  besides  tonsillectomy." 

Sir  Felix  Semon  says:  "I  consider  total  enu- 
cleation not  only  dangerous,  but  also  generally 
superfluous." 

328 


PRINCIPLES  OF  TREATMENT  329 

Marage  says:  "There  is  not  one  treatment  for 
enlarged  tonsils ;  there  are  many  J" 

[Note. — The  most  skilful  and  experienced 
operators  in  the  world  have  reported  deaths  from 
removal  of  the  faucial  tonsils;  the  list  including 
such  eminent  technicians  as  Mayo-Collier^ 
Schmiegelow,  Lennooc-Browne,  Escat,  Sandfort, 
Marage,  Haymann,  Damianos  and  Herman, 
eight  cases;  MacBride,  Zarniko,  Henking, 
Schuchardt,  Burger,  Kenefick,  Thomson,  F. 
Stewart,  Smith,  six  cases ;  E.  M.  Holmes,  Gradle, 
Stucky,  Huhhard,  Goldsmith,  Crockett,  twelve 
cases;  Sewall,  nineteen  cases;  Richadson,  Wish- 
art,  and  others. 

Serious  accide<nts  have  been  reported,  from  the 
removal  of  the  faucial  tonsils  by  the  world's  best 
operators ;  including  Chiari,  Luc,  Semon,  Hajek, 
Escat,  Broeckhaert,  Lennox-Browne,  Wyatt, 
Gronbeck,  St.  Clair  Thomson,  Lack,  Riviere,  150 
cases;  Damianos  and  Hermann,  50  cases;  Hope, 
E.  M.  Holmes,  Quintan,  Hay  man,  21  cases ;  Mur- 
ray, 3  cases ;  Matthews,  Lamb,  Munger,  Roberts, 
Bulson,  Jarecky,  Shurly,  Zarniko,  Beck,  Berger, 
Berens,  GetcJiell,  Hopkms,  Richards,  Hubbard, 
MacBride,  Cohen,  Coley,  Hermann,  Dunbar. 
Phillips,  Tilley,  Nettlebrock,  Leipziger,  Hen- 
king,  Hedges,  Jackson,  Avale,  Huber,  Cline, 
Kan,  Ryan,  E.  J.  B7'own,  Cunningham,  Henkes, 
Wilkinson,  Urban,  Weber,  Woeblews,  and 
others. 

Among  the  accidents  reported  from  removal 
of  the  faucial  tonsil  are:  "Death  from  hemor- 
rhage, immediate  or  secondary,  recurrent  hemor- 
rhage, suspension  of  respiration  and  asphyxia. 


330  THE    TONSILS    AXD    THE    VOICE 

respiratory  arrest,  three  cases ;  cardiac  arrest,  one 
case  (Jackson)  ;  convulsions  from  shock,  mental 
disturbance,  severe  surgical  shock,  deep  slough- 
ing in  tonsillar  region  (Berens)  ;  injury  and 
laceration  of  the  palato-glossei,  palato-pharyn- 
geus  and  superior  constrictor  muscles;  injuiy  of 
the  internal  carotid  (Gray)  ;  injury  of  the  inter- 
nal carotid  by  Pancoast  (George  F.  Steveson)  ; 
injury  of  the  arteria  pharyngea  ascendens  (Hay- 
mann)  ;  injury  of  vomer  (Haymann)  ;  acciden- 
tal removal  of  greater  part  of  the  back  horns  of 
the  turbinated  bones  by  Zarniko  (Haymann)  ; 
injury  of  the  atlas  bone  (Haymann)  ;  injury  to 
uvula,  pillars,  temporary  paresis  of  soft  palate, 
16  cases  (Richards)  ;  paresis  of  the  velum  palati 
)(Castex)  ;  alteration  of  speech  from  injury  to 
pillars,  3  cases  (Richards)  ;  troublesome  hemor- 
rhage (Hajek)  ;  free  hemorrhage  (Beck)  ;  seri- 
ous hemorrhage,  50  cases  with  19  deaths  (Lind- 
ley  Sewall)  ;  dangerous  hemorrhage  (Getchell)  ; 
hemorrhage  (Semon)  ;  hemorrhage,  50  cases 
(Damianos  and  Hermann)  ;  severe  hemorrhage 
(Lamb)  ;  free  hemorrhage  and  death  (Stewart)  ; 
alarming  hemorrhage,  3  cases  (Murray)  ;  serious 
hemorrhage,  3  cases  (Brown)  ;  severe  hemor- 
rhage (Roberts)  ;  secondarj^  hemorrhage,  2  cases 
( Jarecky)  ;  severe  hemorrhage  (Bulson)  ;  severe 
bleeding,  21  cases  (Haymann)  ;  hemorrhage  and 
death  (Haymann)  ;  hemorrhage  and  death  (Zar- 
niko) ;  secondary  hemorrhage  and  death  (Gold- 
smith) ;  alarming  hemorrhage  (Lack)  ;  secon- 
dary hemorrhage  and  death  (Damianos  and  Her- 
mann) ;  fatal  hemorrhage  (Burger)  ;  alarming 
hemorrhage   (Quinlan)  ;  extremely  severe  bleed- 


PRINCIPLES  OF  TREATMENT  331 

ing  (Hope)  ;  severe  hemorrhage  (Escat)  ; 
secondary  hemorrhage  (Thomas)  ;  miusiial 
hemorrhage,  2  cases  (Dunbar)  ;  hemorrhage 
(Leipziger)  ;  alarming  hemorrhage,  2  cases 
(Brainard)  ;  secondary  hemorrhage  (Weber)  ; 
alarming  hemorrhage  (Bulson)  ;  hemorrhage 
(Urban)  ;  severe  hemorrhage  (Ryan)  ;  grave 
hemorrhage  (Cline)  ;  secondary  hemorrhage,  3 
cases  (Kan)  ;  hemorrhage  (Wilkinson)  ;  severe 
hemorrhage,  syncope  (Luc)  ;  hemorrhage,  6 
cases  (Henking)  ;  alarming  hemorrhage  (Le- 
land)  ;  severe  hemorrhage,  3  cases  (Tilley)  ; 
hemorrhage  (Nettlebrock)  ;  repeated  hemor- 
rhages (Cunningham)  ;  alarming  secondary 
hemorrhages  (Chapman)  ;  severe  post-operative 
hemorrhages,  3  cases  (Barrell  and  Orr)  ;  secon- 
dary hemorrhage  (Avale)  ;  severe  infection  of 
the  wound  (Haymann)  ;  hyperpyrexia  and  death 
(Richardson)  ;  hyperpyrexia  and  death  (Wish- 
art)  ;  hyperpyrexia  and  death  (Ward)  ;  general 
sepsis  and  death  (Dean)  ;  gangrene  of  the  mus- 
cles of  the  neck  (Dean)  ;  gangrene  and  death 
(Kinle)  ;  status  lymphaticus  and  death  (Dench) , 
(Harris),  (Packard);  pneumonia,  2  cases  and 
one  death  (Crockett)  ;  diphtheria  of  the  wound 
(Lennox-Browne),  (Caille)  ;  septic  inflammation 
of  adjacent  tissues;  Vincent's  angina  and  death; 
lateral  pharyngeal  abscess  (Huber)  ;  abscess  of 
palate,  removal  of  one  line  of  defense  against 
microbic  invasion  (Ballenger)  ;  severe  infective 
inflammation  of  cervical  glands  (Gronbeck)  ; 
general  staphylococcus  infection,  with  staphylo- 
coccus current  in  all  the  organs  (E.  M.  Holmes)  ; 
subcutaneous    surgical    emphysema     (Parrish)  ; 


332  THE    TONSILS    AND    THE    VOICE 

sej)tic  infection  of  serous  membranes  (Coley)  ; 
development  of  latent  tuberculosis  in  adjacent 
glands  and  pulmonary  tuberculosis  (Ballen- 
ger)  ;  cervical  adenitis  (E.  M.  Holmes)  ; 
hematoma  in  fauces  (Ledermann)  ;  pneumonia 
(Hubbard)  ;  cerebral  meningitis  (Putnam)  ; 
goitre,  Basedow's  disease;  torticollis  (wry-neck) 
(Hedges)  ;  permanent  torticollis  (Pierce)  ;  endo- 
carditis, rheumatic  arthritis,  inflammation  of 
Eustachian  tube,  inflammation  of  middle  ear, 
affecton  of  the  ear  drum,  noises  in  the  ear,  acute 
otitis  and  mastoid  disease  (Citcelli)  ;  double  otitis 
media  with  double  mastoiditis  (Richards)  ;  deaf- 
ness, affection  of  vision,  development  of  sarcoma 
(Delie)  ;  laryngitis,  spasm  of  glottis  (Cohen, 
Sewall)  ;  hoarseness,  permanent  impairment  of 
the  singing  voice  (Chiari,  Lamperti,  Loewen- 
berg,  Shakespeare,  Sebastiani,  Cappiani,  Schu- 
mann-Heink,  Mott,  Bispham)  ;  tonsilliprive  (Es- 
cat)  ;  profound  anaemia,  St.  Vitus'  dance,  gen- 
eral loss  of  health  and  strength,  reflex  nervous 
diseases,  extreme  contraction  of  wound,  trouble- 
some cicatrices,  re-growth  of  tonsillar  tissue  in  all 
cases  (Levinstein,  Brieger,  Goerke,  Escat,  Ma- 
rage,  Grober)  ;  recuiTent  tonsillitis." 

Haymann  says:  "The  habit  of  reporting  bad 
results  is  not  often  followed." 

Richardson,  Washington  Medical  Annals, 
Volume  XI,  Number  2,  says:  "It  is  a  great 
misfortune  that  operators  fail  to  report  the  com- 
plications of  tonsillectomy." 

In  the  New  York  Medical  Journal,  of  August 
17, 1907,  there  appeared  an  article  on  ''Litigation 
of  the  External  Carotid  Artery  in  Rhinology  and 


PRINCIPLES  OF  TREATMENT  333 

Pharyngology."  in  which  its  author  states  that 
"he  is  convinced  that  the  manifold  use  of  external 
carotid  ligation,  and  the  ease  and  safety  of  its 
performance  are  not  fully  recognized.  Ligation 
of  the  external  carotid  is  relatively  a  trivial 
matter,  compared  with  the  more  serious  ligation 
of  the  internal  and  common  carotids."  He  states 
that  he  "Has  tied  the  external  carotid  artery 
thirty-eight  times  in  thirty  cases,  both  arteries 
being  tied  in  eight  cases;  to  arrest  hemorrhage 
after  tonsillectomy,  seven  cases ;  to  forestall  hem- 
orrhage in  extirpation  of  malignant  disease  of 
the  tonsil  and  tongue,  four  cases;  to  forestall 
hemorrhages  in  extirpation  of  malignant  disease 
of  the  maxillary  antrum,  three  cases;  to  inhibit 
growth  in  malignant  disease  of  the  maxillary  an- 
trum, four  cases ;  to  forestall  hemorrhage  in  ex- 
tirpation of  naso-pharyngeal  fibromata,  eight 
cases;  to  arrest  spontaneous  nasal  hemorrhage, 
two  cases;  to  arrest  post  operative  nasal  hemor- 
rhage, two  cases." 

"After  tonsillectomy,  many  serious  and  a  few 
fatal  hemorrhages  have  occurred." 

In  the  Annals  of  Surgery,  of  December,  1907, 
in  an  article  on  ''Tonsillar  Hemorrhage  and  its 
Surgical  Treatment/"  by  the  same  operator,  he 
states  that: 

"Few  operations  in  surgery  are  done  so  badly 
as  those  upon  the  tonsils.  Tonsillectomy  is  an  ex- 
ceedingly difficult  operation  to  do  ideally.  Per- 
sonally, the  author  is  satisfied  with  but  few  of  his 
tonsillectomies." 

"Tonsillotomy  is  an  easy  but  an  utterly  un- 
justifiable operation.    Such  an  operation  seals  up 


334  THE    TONSILS    AND    THE    VOICE 

the  glandular  tissue  of  the  tonsil  under  bands  of 
cicatricial  tissue  which  forever  will  interfere  with 
throwing  oiF  of  leucocytes,  secretions,  epithelial 
and  other  debris.  Rheumatism,  infective  arthritis, 
endocarditis,  tuberculosis  and  a  host  of  other  ills 
that  modern  research  has  traced  in  many  instances 
to  the  tonsils  are  made  worse  or  their  oc- 
currence is  rendered  more  likely  by  incomplete  re- 
moval." 

If  tonsillotomy  "seals  up  the  glandular  tissue 
of  the  tonsil,"  as  the  above  tonsillectomist  asserts, 
then  will  not  the  facilities  for  absorption  of  bac- 
teria be  "sealed  up"  to  precisely  the  same  degree 
as  the  facilities  for  throwing  off  of  leucocytes  ? 
Entrance  and  exit  should  be  equally  affected. 

The  statements  of  the  operator  quoted  are  not 
in  accord  with  modern  research  authorities. 
Eugene  Hodenpyl,  a  research  authority,  found 
upon  research  investigation  that  "the  faucial  ton- 
sil in  normal  condition  absorbs  neither  liquids  nor 
solids."  The  researches  of  Menzer,  Hendelssohii, 
Lexer  and  Groher  confirm  those  of  Hodenpyl. 
Frdnkel  has  shown  that  "children  affected  with 
hyperplastic  tonsils  are  less  easily  affected  by 
diphtheria  than  children  with  normal  tonsils." 

That  great  pediatric  authority,  A.  Jacohij  in 
the  Archives  of  Pediatrics^  July,  1906,  states 
that: 

"Exposure  and  many  diseases  change  the  sur- 
face and  structure  of  the  tonsil.  Every  new  in- 
flammation changes  them.  New  cell  infiltration 
and  cicatricial  tissue  renders  absorption  less  pos- 
sible. That  is  why  in  advanced  life  the  tonsil  gets 
harder  and  smaller,  and  infections  become  less. 


PRINCIPLES  OF  TREATMENT  335 

The  same  deleterious  influence  will  no  longer 
prove  effectual." 

Von  Levinstein  states  that  "Hardening  of  the 
surface  of  the  tonsil  is  very  desirable,  in  that  it 
prevents  any  possible  absorption  of  materes  morbi 
by  the  organ." 

The  operator  quoted  above  represents  the  ex- 
tremitj^  in  radical  operative  surgery.  Radicalism 
has  an  intrinsic  value,  but  in  operative  surgery 
adds  greatly  to  the  surgeon's  responsibility,  and 
imposes  upon  him  eoctraordinary  obligations  in 
diagnostic  ability,  supreme  caution  in  positions 
of  perilj  and  at  all  times  an  erudite  and  conscie^i- 
tious  selection  of  cases. 

"Bold  in  security  and  cautious  in  danger"  is 
a  safe  surgical  aphorism. 

The  operator  who  has  tied  so  many  external 
carotids,  will  find  few  followers.  It  will  be  easier 
for  him  to  destroy  the  external  carotid  artery, 
than  to  convince  educated  and  experienced  physi- 
cians of  his  right  in  doing  so.  The  external 
carotid  is  an  exceedingly  important  artery;  and 
while  it  may  be  a  ''trivial"  act  to  tie  this  vessel, 
the  result  of  tying  it  will  never  become  a  "trivial" 
jnatter. 

Briefly  consider  the  function  of  the  external 
carotid.  It  carries  the  blood  to  the  head  and  neck. 
It  nourishes  the  face  and  nose  and  skin,  muscles, 
nerves,  and  bones ;  it  nourishes  the  muscles  of  the 
larynx,  epiglottis,  pharynx,  tongue  and  jaw;  the 
muscles  of  the  hyoid  bone,  the  tensor  and  levator 
palati,  the  soft  palate,  the  middle  and  inferior 
constrictors  of  the  pharynx,  the  masseter,  buc- 
cinator, temple  muscles,  etc. 


336  THE    TONSILS    AND    THE    VOICE 

It  nourishes  the  hning  membrane  of  the  larynx, 
pharynx,  mouth,  gums,  nose,  antrum  of  High- 
more,  ethmoid  and  sphenoid  cells ;  the  integument 
of  the  lips,  face,  forehead,  scalp,  pericranium,  the 
dura  mater,  the  Eustachian  tube,  tympanum  of 
the  ear,  mastoid  cells,  semicircular  canals  and 
cartilages  of  the  ear.  It  nourishes  the  tonsils, 
thyroid  gland,  laryngeal  glands,  sublingual, 
palatine,  submaxillary,  and  lymphatic  glands  of 
the  neck. 

It  nourishes  the  teeth,  alveolar  process,  gums 
and  nasal  septum. 

It  nourishes  the  ganglion  of  the  fifth  nerve, 
the  facial  nerv^e,  the  sympathetic,  hypoglossal 
and  pneumogastric  nerves. 

I  cannot  believe  that  any  "manifold  use"  will 
popularize  the  shutting  off  of  nourishment  to  the 
area  above  mentioned,  even  though  it  may  be 
shut  off  "with  ease  and  safety." 

A  question  of  interest  in  regard  to  the  thirty- 
eight  ligations  lies  in  the  fact  that  thirty  lives 
were  so  jeopardized  by  hemorrhages,  actual  or 
prospective,  in  the  personal  experience  of  this  one 
laryngectomist,  as  to  seem  to  demand,  in  his 
judgment,  such  an  extreme  measure  as  the  tying 
of  the  external  carotid  artery.  Of  course,  to  tie 
this  artery  is  to  starve  the  parts  which  it  supplied, 
except  by  anastomosis.  We  may  hope  that  by 
anastomosis  the  vessels  of  one  side  of  the  head 
will  sufficiently  nourish  both  sides.  But  anasto- 
mosis can  hardly  be  expected  to  take  place  to  an 
extent  that  the  arteries  of  the  one  side  of  the  head 
will  take  complete  care  of  the  arterial  function 


PRINCIPLES  OF  TREATMENT  337 

of  the  whole  head  as  nature  designed  by  the  orig- 
inal vessels. 

Besides,  we  must  remember  that  the  operator 
quoted  tied  the  external  carotids  on  both  sides  in 
eight  patients. 

In  the  thirty-eight  ligations,  the  operator  does 
not  state  the  nature  of  the  eight  cases  in  which 
he  tied  both  arteries. 

Seven  cases  out  of  the  thirty  were  done  to  stop 
bleeding  after  tonsillectomy.  It  would  be  highly 
interesting  to  know  the  exact  original  conditions 
of  the  tonsils  in  these  seven  cases,  that  seemed  to 
require  tonsillectomy,  which  were  followed  by 
such  alarming  hemorrhages  as  to  apparently 
necessitate  ligation  of  the  external  carotids. 

Without  the  data  of  the  original  conditions 
that  seemingly  indicated  tonsillectomy,  students 
in  modern  physiological  research  may  view  the 
question  of  surgical  triumph  in  at  least  a  portion 
of  these  thirty-eight  ligations  with  lessened  in- 
terest; and  in  the  absence  of  the  original  light, 
might  even  consider  tonsillectomies  that  necessi- 
tated subsequent  ligation  of  the  external  carotids 
as  possible  surgical  blunders.  The  original  ton- 
sillar conditions  that  preceded  the  tonsillectomies 
which  caused  post-operative  hemorrhages  that 
led  to  the  ligations  would  be  interesting  to  know. 

With  the  announcement  of  his  thirty-eight 
ligations,  the  operator  ends  his  narrative. 

How  unfortunate!  What  rare  opportunity 
these  thirty-eight  operations  would  have  fur- 
nished for  subsequent  scientific  study  of  the  ef- 
fects of  altered  or  impaired  nutrition  of  the 
nerves  that  control,  and  of  the  delicate  muscles 

23 


338  THE    TONSILS    AND    THE    VOICE 

involved  in,  the  processes  of  phonation  and  deglu- 
tition, of  the  acuteness  of  audition,  and  of  the 
general  impairment  of  nutrition  in  the  face,  in 
the  nose,  etc.  What  a  great  opportunity  was 
lost! 

The  excessive  evil  role  charged  against  the  ton- 
sil has  not  been  proved  by  any  established  facts 
in  scientific  pathology.  That  patients  are  scared 
into  operations  is  a  common  observation.  And 
false  statements  regarding  benefits  that  are  al- 
leged to  follow  are  daily  showTi  to  be  untrue. 

False  evidence  is  sometimes  offered  by  those 
even  in  positions  of  high  authority. 

Lennox  Broxicne  and  Emil  Belinkej,  in  their 
work  entitled  '"Voice,  Song  and  Speech"  (Sev- 
enth Edition)  1887,  make  the  false  statement 
that  "Unfortunately  there  is  a  prejudice,  very 
ill-founded  and  unsupported  by  any  authoritj^ 
against  the  radical  cure  by  removal  of  enlarged 
tonsils.  There  is  no  argument  whatever  of  any 
scientific  value  to  be  advanced  against  the  mea- 
sure, and  there  is  the  very  direct  evidence  in  its 
favor  of  many  of  our  great  singers.  Louisa 
Pyne,  Patti,  Lucca  and  others  have  undergone 
the  operation,  not  onlj^  without  injury,  but  with 
actual  benefits." 

Louisa  Pyne  and  Lucca  are  dead.  Patti  lives, 
hut  denies  the  statement.  The  name  of  no  other 
prima  donna  has  ever  been  published;  and  I  do 
not  believe  that  any  prima  donna  ever  lived  whose 
voice  was  improved  by  enucleation.  Not  one 
case  can  I  find  of  a  prima  donna  whose  voice  was 
improved  by  enucleation. 


PRINCIPLES  OF  TREATMENT  339 

Gordon  Holmes,  in  his  work  on  ''Vocal  Physi- 
ology," Third  Edition,  1900,  remarks: 

''It  is  stated  that  many  of  our  greatest  singers, 
from  Madame  Patti  downwards,  have  under- 
gone the  operation  of  removal  of  the  tonsils  with 
the  best  resulis." 

These  statements  of  Browne  and  Behnke,  Sir 
Gordon  Holmes  and  others,  regarding  Madame 
Adelina  Patti,  now  the  Baroness  Cedarstrom, 
are  absolutely  untrue,  as  proved  by  the  following 
answer  of  March  2,  1910,  of  the  Baroness,  to  my 
letter  of  inquir-y : 

"2/3/10  Craig-y-Nos  Castle, 

"Penycae,  S.  O., 

"Telegrams         .  "Breconshire. 

"Abercrave,  S.  O. 
"Dr.  R.  B.  FaulkneRj 
"Pittsburgh. 
"Dear  Sir: — The  Baroness  Cedarstrom  is  in 
receipt  of  your  letter  of  the  14th  inst.  and  desires 
me  to  say  that  she  regrets  her  inability  to  give 
you  the  desired  information  as  she  has  never  had 
any  operation  on  her  throat  or  trouble  with  the 
tonsils. 

"Yours  faithfully, 
"H.  D.  Alcock,  Sec'y."] 


340  THE    TONSILS    AND    THE    VOICE 

The  routine  enucleation  of  the  tonsils  is  con- 
demned not  only  hy  Mackenzie,  at  Johns  Hop- 
kins University,  and  hy  Swain,  at  Yale,  hut  also 
hy  authorities  at  Harvard  University,  Columbia, 
Pennsylvania,  Vienna,  Berlin,  Paris,  London 
and  elsewhere. 

Enucleation  of  the  faucial  tonsil  is  co?isidered 
by  the  authorities  to  be  a  capital  operation;  more 
dangerous  than  amputation  of  the  leg  at  the 
hip- joint;  more  fatal  than  removal  of  the  appen- 
dix; and  also  to  involve  the  destruction  of  values 
in  the  mechanism  of  song  and  speech. 

The  intelligent  treatment  of  a  diseased  tonsil 
implies  a  clear  understanding  of  what  constitutes 
a  normal  tonsil. 

The  normal  tonsil  must  represent  a  type.  Dis- 
ease represents  departure  from  the  type. 

A  knowledge  of  the  anatomy  and  physiology 
of  the  normal  type  is  essential  in  permitting  one 
to  note  departures;  and  to  aid  him  in  restoring 
the  organ  to  the  normal. 

When  the  eye  becomes  affected  with  cataract, 
or  when  strabismus  occurs,  it  is  unnecessary  to 
enucleate  the  eye.  Neither  is  it  necessarj^^  to 
enucleate  the  tonsil,  just  because  one  or  two  of  the 
follicles  happen  to  become  diseased.  The  same 
standard  in  education  that  requires  an  operator 
on  the  eye  to  have  full  knowledge  of  the  anatomy 
and  phj^siology  of  that  organ  should  apply  with 
equal  force  to  an  operator  on  the  tonsils. 

A  greater  variety  and  a  more  incongruous  en- 
semble of  opinions  is  inconceivable,  than  are  now 
held  by  the  general  ]3rofession  regarding  the 
treatment  of  diseased  tonsils. 


PRINCIPLES  OF  TREATMENT  341 

Hicguet  (Brussels)  in  the  report  of  his  re- 
searches on  the  ''Functions  and  Utility  of  the 
Faucial  Tonsil/'  to  the  Societe  Beige  dfOtologie, 
de  Rhinologie  et  de  Laryngologie,  "complained 
that  the  diversity  of  theories  which  he  had  met 
with  in  his  work  had  put  him  to  much  pains  to 
form  the  conclusions  at  the  end  of  his  report." 

The  perplexity  of  Hicguet  may  he  appreciated 
when  such  an  eoccellent  man  as  H.  Holbrook 
Curtis,  in  reply  to  my  research  question:  Have 
the  normal  faucial  tonsils  any  function,  phj^sio- 
logic,  biologic,  chemical,  phonetic,  or  other?  an- 
swered, "In  my  opinion — no."    (March  3,  1910.) 

And  in  his  book,  entitled  ''Voice  Building  and 
Tone  Placing"  he  remarks:  "They  are  best  re- 
moved, if  they  give  the  slightest  trouble." 

And  when  Eugene  Hodenpyl  replied  to  the 
same  question:  "The  function  of  the  faucial  ton- 
sil is  unknown."  And  when  G.  Hudson-Ma- 
kuen  replied  to  the  same  question:  "I  do  not 
know"  (December  17,  1909).  And  in  the  New 
York  Medical  Journal,  June  19,  1909,  he  re- 
marks : 

"Generally  speaking,  a  visible  tonsil  is  abnor- 
mal and  pathological.  The  more  diseased  and 
consequently  the  more  harmful  tonsil  is  the  one 
that  is  scarcely  visible  at  all" 

"The  diseased  tonsil  should  be  removed  in  toto 
with  its  capsule  intact.  I  have  said  that  the 
faucial  tonsils  are  the  seat  of  numerous  opera- 
tions and  I  shall  go  further  and  say  that  these 
operations  should  be  far  more  nuinerous  and 
more  radical.  I  think  I  am  pecidiarly  qualified 
to  speak  with  authority  upon  this  subject,  be- 


V 


342  THE    TONSILS    AND    THE    VOICE 

cause  of  my  unusual  opportunities  for  careful 
studies  of  the  mouth  and  fauces  both  before  and 
after  operations  in  connection  with  my  work  in 
defects  of  speech." 

And  again,  in  the  Transactions  of  the  Ameri- 
can Laiyngological  Association,  1911,  he  says: 
"There  is  no  absolute  standard  of  vocal  excel- 
lence, and  the  voice  that  sounds  good  to  one  per- 
son may  sound  very  different  to  another. 
Whether  a  voice  is  good  or  bad  depends,  not  actu- 
ally, but  practically,  upon  the  ear  of  the  listener. 
This  fact  may  account,  perhaps,  for  the  great 
difference  of  opinion  now  prevailing  as  to  the 
effect  of  tonsil  operations  upon  the  voice." 

And  when  Edwin  Pynchon,  in  reply  to  my 
question.  What  are  the  functions  of  the  faucial 
tonsils?  says: 

"I  am  disposed  to  think  that  they  have  no 
function  except  to  cause  trouble.  I  frequently 
remove  tonsils  which  have  been  passed  upon  by 
other  specialists  as  being  'normal'."  (December 
11,  1909.) 

And  in  the  Alkaloidal  Clinic,  October,  1897, 
he  says: 

"The  exact  cause  of  hypertrophy  of  the  tonsils 
is  not  clearly  knoTvu.  For  all  these  conditions 
enumerated,  depending  upon  enlargement  or  de- 
generation of  the  tonsils,  a  positive  cure  can  he 
guaranteed.  The  only  rational  treatment  is  sur- 
gical, viz. :  the  thorough  and  total  ablation  of  all 
hvpertrophied  or  diseased  folHcle-bearing  tis- 
sue." 

And  in  the  Journal  of  the  American  Medical 
Association,  March  21,  1903,  he  savs: 


PRINCIPLES  OF  TREATMENT  343 

"While  many  of  the  chronic  diseased  condi- 
tions of  the  tonsil  possess  individual  characteris- 
tics under  microscopic  examination,  the  impor- 
tance of  differentiating  the  several  varieties  which 
have  been  described  is  much  diminished  by  the 
fact  that  any  and  all  of  the  simple  chronic  forms 
of  tonsillar  disease  are  equally  amenable  to  the 
same  treatment,  viz.:  that  of  thorough  eradica- 
tion." 

And  in  the  Illinois  Medical  Bulletin,  April, 
1905,  he  says:  "While  different  theories  have 
been  advanced  as  to  the  functions  of  the  tonsils, 
none  of  them  have  been  proved;  and  the  undis- 
puted clinical  fact  remains,  that  the  patient  in- 
variably improves  in  health  after  their  removal." : 

And  when  Charles  M.  Robertson,  Journal  of 
The  American  Medical  Association,  August, 
28,  1909,  says: 

''If  the  tonsil  in  a  normal  state  is  removed 
in  toto  there  is  no  disastrous  after  effect,  as  in  the 
case  of  the  thyroid.  On  the  other  hand,  the  in- 
dividual is  improved  in  health.  It  is  claimed  that 
the  tonsils  in  particular  cases,  has  come  to  have  a 
function  in  modulating  the  voice.  This,  however, 
I  look  on  as  a  mere  matter  of  education,  and  the 
singer  or  speaker  would  have  come  to  modulate 
the  voice  just  as  well  without  this  gland  as  with 
it.  On  the  other  hand,  we  have  all  seen  cases  in 
which  the  voice  was  increased  in  tone  and  volume 
by  the  removal  of  these  growths.  The  richness 
of  quality  and  volume  of  tone  is  often  added  to 
100  per  cent,  after  the  enucleation." 

And  when  William  L.  B  alien ger  in  his  work 


344  THE    TONSILS    AND    THE    VOICE 

entitled  "Diseases  of  the  Nose,  Throat  and  Ear" 
1908,  states: 

"Singers  and  public  speakers,  with  a  trouble- 
some subacute  laryngitis,  whose  tonsils  are  small 
and  fibrous,  or  enlarged,  may  be  benefited  hy  the 
complete  ablation  of  the  tonsils.  The  function 
of  the  tonsils  in  a  child  and  in  an  adult  is  still  an 
open  question.  It  is  being  more  and  more  recog- 
nized that  the  complete  enucleation  of  the  tonsil 
with  its  investing  capsule  is  the  most  satisfactory 
method  of  dealing  with  diseased  tonsils." 

"In  the  following  indications,  it  should  be  re- 
membered that  they  are  given  with  especial  ref- 
erence to  the  complete  operation,  technically 
known  as  tonsillectomy:  (a)  Nasal  catarrh, 
(b)  Ear  Diseases,  (c)  Recurrent  enlargement  of 
the  deep  glands  of  the  neck,  (e)  When  the  crypts 
of  the  tonsils  are  found  more  or  less  filled  with 
debris  and  bacteria,  (f)  Laryngitis  with  attacks 
of  hoarseness,  crypts  diseased,  and  tonsils  hyper- 
trophied,  (g)  Hypertrophy  of  the  tonsil,  (h) 
Chronic  follicular  tonsillitis,  (i)  Follicular 
pharyngitis,  (j)  Tuberculous  infection  of  the 
tonsils,  (k)  Recurrent  acute  articular  rheumatism 
following  acute  tonsillitis." 

And  when  Dan  McKenzie,  British  Medical 
Journal,  November  19,  1910,  says:  "Enuclea- 
tion should  always  he  performed  when  the  tonsil 
is  diseased  and  not  merely  hypertrophied.  There 
is  another  variety  of  the  enlarged  tonsil  which 
should  be  dealt  with  by  careful  removal.  I  refer 
to  what  is  known  as  the  buried  tonsil." 

And  when  St.  Clair  Thomson  in  response  to  my 
query :    Would  you,  as  a  rule,  advise  the  removal 


PRINCIPLES  OF  TREATMENT  345 

of  normal  tonsils?  answered,  "It  is  impossible  to 
define  what  is  a  'normal  tonsil.' " 

And  when  Lermoyez  in  response  to  my  query, 
answered,  "I  consider  that  the  normal  tonsils  are 
organs  that  miist  he  respected.  One  should  never 
remove  the  human  organs:  not  more  a  normal 
tonsil  than  a  healthy  tooth  or  a  healthy  eye!" 

And  when  Barth  answered.  "I  do  not  remove 
normal  or  slightly  hypertrophied  tonsils.  If  one 
wanted  to  do  that,  one  would  have  to  perform  m 
any  normal  man  a  number  of  prophylactic 
operations." 

And  when  Luhet-Barhon  answered, 

"I  think  there  is  never  an  indication  to  remove 
a  normal  organ,  and  for  myself,  I  never  remove 
tonsils  responding  to  the  type  you  call  normal, 
like  volume  and  like  condition  of  the  gland,  with- 
out chronic  inflammation,  without  crypts,  without 
adherence  to  the  pillars,  and  elsewhere." 

And  when  Escat  answered:  "It  is  not  neces- 
sary in  my  opinion,  to  set  one's  heart  upon  com- 
pletely extracting  all  the  tonsillar  tissue  as  vari- 
ous American  confreres  proposed.  The  tonsil  is 
not  an  epithelioma!" 

And  when  Frank  E.  Miller  in  response  to  my 
query,  Would  you,  as  a  rule,  advise  the  removal 
of  normal  tonsils?  answered,  "Never,  if  as  de- 
scribed in  question  number  one." 

And  when  Chiari  answered,  "Greatly  enlarged 
tonsils  in  elder  professional  singers  should  never 
be  removed." 

And  when,  to  the  same  query.  Von  Schrotter, 
Schmeigelow,  Van  Baggen,  Escat,  Moure,  Luc, 
Castex,  Massei,   Gleitsman,  Gleason,  Coolidge 


346  THE    TONSILS    AND    THE    VOICE 

and  others,  declare  that  normal  tonsils  should  not 
he  removed,  it  is  no  wonder  that  Hicguet  was 
pained  in  forming  the  conclusions  to  his  research. 

Judged  by  the  rule  of  Pasteur  that,  ''In  eojperi- 
mental  science  it  is  always  a  mistake  not  to  doubt 
when  facts  do  not  compel  affirmation,''  it  is  perti- 
nent to  ask. 

What  fact  compels  the  affirmation  of  H.  Hol- 
hrook  Curtis,  that  "the  faucial  tonsil  is  best  re- 
moved, if  it  give  the  slightest  trouble"? 

What  fact  compels  the  affirmation  of  G.  Hud- 
son-Mahuen,  that  ''a  visible  tonsil  is  abnormal  and 
pathological" ;  that  'Hhe  more  harmful  tonsil  is 
the  one  that  is  scarcely  visible  at  all;  that  "the 
diseased  tonsil  should  be  removed  in  toto  with  its 
capsule  intact";  that  "operations  should  be  far 
more  numerous  and  more  radical" ;  that  "the 
rather  common  belief  among  the  laity  that  the  re- 
moval of  the  faucial  tonsils  impairs  the  voice  is 
altogether  without  foundation,  except  in  those 
cases  in  which  injury  is  done  to  the  palate  or 
other  surrounding  structures"  {New  York 
Medical  Journal,  June  19,  1909)  :  that  "the  re- 
moval of  tonsils  is  injurious  to  the  voice  is  well 
founded,  and  it  is  due  in  large  measure  to  care- 
less or  bad  surgery"  (Transactions,  American 
Laryngological  Association,  1911)  ? 

What  fact  compels  the  affirmation  of  Edwin 
Pynchon,  that  "he  thinks  the  tonsils  have  no  func- 
tion except  to  cause  trouble^' ;  that  "the  exact 
cause  of  hypertrophy  is  not  known";  that  "for 
all  the  conditions  he  enumerates,  depending  upon 
enlargement  or  degeneration,  a  positive  cure  can 
be  guaranteed'' ;  that  "the  importance  of  differ- 


PRINCIPLES  OF  TREATMENT  347 

entiating  the  several  varieties  Is  much  diminished 
by  the  fact  that  they  are  equally  amenable  to  the 
same  treatment"? 

What  fact  compels  the  affirmation  of  Charles 
M.  Robertson,  that  "If  the  tonsil  in  a  normal, 
state  is  removed  in  toto  there  is  no  disastrous  after 
effect,  as  in  the  case  of  the  thyroid.  On  the  other 
hand,  the  individual  is  improved  in  health" ;  that, 
"The  richness  of  quality  and  volume  of  tone  is 
often  added  to  100  per  cent,  after  the  enuclea- 
tion"? 

What  fact  compels  the  affirmation  of  William 
L.  Ballenger,  that  "singers  and  public  speakers 
with  troublesome  subacute  laryngitis,  may  be 
benefited  by  the  complete  ablation  of  the  ton- 
sils"; that  "it  is  being  more  and  more  recognized 
that  the  complete  enucleation  is  the  most  satis- 
factory method  of  dealing  with  diseased  tonsils"? 

What  fact  compels  the  affirmation  of  Dan 
McKenzie,  that  "enucleation  should  always  be 
performed  when  the  tonsil  is  diseased,  and  not 
merely  hypertrophied"  ? 

What  fact  compels  affirmation  of  Stohr's 
statement,  that  "the  surface  of  the  tonsil  presents 
openings  that  maj'-  allow  the  entrance  of  infec- 
tious material"? 

What  fact  compels  the  affirmation  of  MandVs 
statement,  that  "excision  of  enlarged  tonsils  is 
followed  by  no  inconvenience  to  the  voice,  hut  is 
always  beneficial  to  it"  ? 

What  fact  compels  the  affirmation  of  the  state- 
ments of  Lennooo  Browne  and  Emit  Behnke, 
Sir  Gordon  Holmes  and  others,  that  ''Many  of 
our  greatest  singers,  from  Madame  Patti  down- 


348  THE    TONSILS    AND    THE    VOICE 

wards,  have  had  their  tonsils  removed,  not  only 
without  injury,  hut  with  actual  benefits  to  the 
voice"? 

The  many  deaths,  the  numerous  accidents,  the 
unskilled  army  of  operators,  and  the  sharp  criti- 
cisms of  men  who  stand  high  as  medical  authori- 
ties, added  to  the  strong  protest  of  the  whole 
voice  profession  and  of  thousands  of  intelligent 
laymen,  make  the  radical  revision  of  tonsillar 
treatment  and  a  reasonable  unity  of  professional 
proceeding,  an  urgent  and  absolute  necessity. 

When  Von  Levinstein,  in  his  critical  review, 
states  that  "No  physiological  function  has  been 
proved  for  the  faucial  tonsil";  when  Hodenpyl 
declares  that  "its  physiological  function  is  un- 
known" ;  when  H.  Holbrook  Curtis  says  that,  in 
"his  opinion,  it  has  no  function";  when  Scripture 
states  that  "it  has  no  known  phonetic  use" ;  when 
Lubet  Barhon,  Coolidge,  and  G.  Hudson-Ma- 
kuen  say  they  "do  not  know  its  function" ;  when 
Luc  "has  no  personal  views  on  the  subject  of  its 
function";  when  Wesley  Mills  believes  its  func- 
tion is  so  slight  that  its  work  can  be  readily  com- 
pensated for  by  other  organs";  when  St.  Clair 
Thomson  says:  "It  is  impossible  to  define  what 
is  a  'normal'  tonsil";  when  Sir  Felix  Semon  de- 
clares that,  ''I  do  not  believe  that  an  extension  of 
the  range  of  the  voice  usually  follows  removal  of 
the  tonsils";  when  Sebastiani  states  that  "the 
greater  the  development  of  the  tonsils  the  greater 
is  the  difficulty  with  resonance  and  with  the  emis- 
sion of  the  tones  of  the  second  register  or  high 
notes :  even  the  removal  of  the  normal  tonsils  does 
not  facilitate  these  high  sounds";  when  Chiari 


PRINCIPLES  OF  TREATMENT  349 

declares  that  "In  elder  professional  singers  d\ 
peculiar  disturbance  of  the  voice  occurs  if  their\ 
large  tonsils  have  been  removed;  the  faucial 
arches  lose  their  support,  the  faucial  muscles  can- 
not contract  properly;  the  resonance  of  the  voice, 
is  impaired,  and  the  tones  suffer  in  strength  and 
fulness" ;  when  Loewenberg  says,  "I  do  no  know^ 
of  any  case  in  which  a  singer's  voice  was  improved 
by  the  removal  of  normal  tonsils.  On  the  con- 
trary, I  know  of  cases  in  which  the  removal  of 
normal  tonsils  have  caused  permanent  detrimen- 
tal effects  to  the  voice.  For  these  reasons,  I  dis- 
approve of  operations  upon  normal  tonsils  in  all 
cases";  when  Mme.  Cappiani  {Hints  and  Helps 
in  Singing) states:  "I  complained  about  my  red 
and  big"  tonsils.  But  my  brother,  Frederic 
Young,  dramatic  tenor  for  years,  at  the  Royal 
Court  Opera  in  Munich,  said  he  found  in  his 
career  that  all  those  prima-donnas  with  extraor- 
dinary voices,  had  big  tonsils";  when  John 
Howard  says,  "The  greater  size  of  the  tongue  is 
noted  when  the  voice  is  full  and  resonant.  The 
renowned  Catalini,  Lablache,  and  Santini  fur- 
nished examples";  when  Masini  and  E.  L. 
Shurly  think  "It  has  an  internal  secretion";  when 
Escat  in  accord  with  Allen  is  "of  the  opinion  that 
it  secretes  a  principle,  useful  in  the  development 
and  growth  of  the  subject,  and  probably,  to  the 
growth  of  the  skeleton'";  when  Metchnikoff , 
Chiari,  Schmiegelow,  Massei,  Barth,  and  Gleits- 
mann  believe  "that  it  has  a  leucocytic  protective 
function";  when  Brieger,  Goerke  and  Frdnkel 
teach  that  "it  has  a  protective  mechanism";  when 
Frdnkel  "denies  the  statement  of  Stohr  that  the 


350  THE    TONSILS    AND    THE    VOICE 

surface  of  the  tonsil  presents  an  open  wound  for 
infections  to  enter";  when  D.  Bryson  Delavan 
states  that  "removal  of  tonsils  was  probably  one 
of  the  earliest  operations  known,  and  the  fact  that 
for  many  generations  it  was  abandoned  rather 
points  to  the  belief  that  there  must  have  been 
some  good  cause  for  its  abandomnent  and  he 
urges  caution  in  returning  to  tonsillectomy  as 
a  routine  practice";  when  Swain  "deplores  ton- 
sillectomy as  a  routine  practice  in  young  chil- 
dren" ;  when  Groher  says  that  "The  tonsils  seem 
to  be  a  less  favorite  settling  place  for  tubercle 
bacilli  than  the  lymph  glands" ;  when  Moure  be- 
lieves "It  has  physiologic,  biologic,  chemical  and 
phonetic  functions" ;  when  Gleason  thinks  "It  has 
other  functions  besides  those  of  the  lymphatic 
system";  when  Von  Levinstein,  Frdnkel,  Escat 
and  Lermoyez  state  that  ''You  should  cure  the 
tonsil  when  it  is  diseased''  that  ''you  have  no 
authority  to  remove  it" ;  when  Loewenherg  says, 
"Normal  tonsils,  according  to  my  experience, 
should  never  be  removed  bj^  operation,  neither  on 
account  of  the  effect  upon  the  general  health, 
nor  of  the  functional  activity  of  the  organ  itself. 
Even  though  the  physiological  significance  of  the 
tonsil  still  rests  upon  a  hypothesis,  this,  like  any 
other  healtlty  organ  in  the  body,  should  be  left 
undisturbed";  when  Sir  Felix  Semon  and  John 
N.  Mackenzie  "deplore  the  discrediting  effects 
of  intemperate  surgery  upon  the  specialty  of 
laryngology";  when  Frank  E.  Miller  considers 
"the  tonsil  to  be  a  regulator  of  pillar  action"; 
i  when  Van  Bag  gen  states  that  "it  certainly  has  a 
phonetic  function ;  that  its  position  between  the 


PRINCIPLES  OF  TREATMENT  35I 

])illars  of  the  fauces  is  of  great  importance  with 
regard  to  the  exactitude  and  perf  ectness  of  move- 
ments of  the  pillars  and  muscles  of  the  soft 
palate";  when  Lamperti  and  Mme.  Capjnani 
state  that  "the  tonsils  are  most  necessary  for 
modulation  in  singing,  that  without  them  it  is 
difficult,  sometimes  impossible,  for  the  voice  to 
modulate";  when  Mme.  Mott  says  "the  normal 
tonsils  are  of  use  to  singers,  in  so  far  as  they  pre- 
serve the  original  structure  of  the  throat,  on 
which  depends  the  original  beauty  of  the  voice" ; 
when  Hubbard  states  that  "after  their  removal 
there  is  a  difficulty  in  assuming  different  shapes 
of  the  pharynx  necessary  in  singing,  causing  a 
hardness  in  quality  and  laborious  action";  when 
Mme.  Everett  says,  that  "after  removal  of  the 
tonsils  there  is  always  something  gone  from  the 
voice  that  does  not  come  back — the  personal 
charm";  when  Mme.  Lilli  Lehmann  "gives  warn- 
ing to  singers  against  unprincipled  physicians 
who  daub,  burn,  cut,  and  make  everything  about 
the  larynx  worse  instead  of  better";  when  Sal- 
vatore  Marchesi  "charges  a  class  of  laryngolo- 
gists  with  betraying  their  scientific  mission,  and 
with  creating  disorders  and  diseases  among  sing- 
ing people";  when  Frederic  Young  states  that 
"all  the  prime  donne  he  had  ever  known,  whose 
voices  were  of  particular  quality  and  value,  had 
large  tonsils";  when  Garcia,  Mme.  Viardot- 
Garcia  and  Mme.  Von  Klenner  "objected  serious- 
ly to  any  operation  upon  a  normal  throat  for  the 
purpose  of  improving  the  singing  voice" ;  when 
Mme.  Lilli  Lehmann  "will  never  advise  the  re- 
moval of  anything  from  the  singer's  throat,  but 


352  THE  to:nsils  and  the  voice 

would  always  tiy  to  cure  it  without  any  opera- 
tion"; M^hen  Charles  A.  Rice  considers  "the 
removal  of  any  part  of  a  normal  tonsil  un- 
necessary, and  that  it  will  in  no  way  aid  tone 
production  or  quality";  when  Mine.  San  Carola 
says,  "Even  when  tonsils  are  abnormally  large, 
she  always  opposes  any  proposal  to  remove  them 
b}^  surgery";  when  Jean  de  Reszke  "knows  of 
only  one  case  ainong  all  his  pupils  of  the  ton- 
sils having  been  removed";  and  Sabatini  has 
'^only  twice  ever  recommended  removal  of 
tonsils  (both  cases  being  abnormal)";  and 
Van  Bag  gen  "has  advised  the  removal  of  only 
two  tonsils  in  eight  years'" ;  when  Laniperti, 
Mine,  Cappiani,  Mme.  Mott,  Bristol,  "are  de- 
cidedly opposed  to  the  growing  tendency  of  re- 
moving tonsils  in  singers";  when  Curry  "never 
knowingly  had  a  pupil  whose  tonsils  were  re- 
moved"; when  Lamperti,  Mine.  Cappiani,  Sir 
Charles  Santley,  Mme.  Mott,  Sabatini,  Mme. 
Von  Klenner,  Sweet,  Hubbard,  Townsend,  Mme. 
Lillian  Nordica,  Mme.  Schumann-Heink,  Mme. 
Tetrazzini,  Bond,  Bispham,  David  C.  Taylor, 
Miss  Cecelia  Winter,  "have  never  known  of  an 
\  instance,  in  which  the  singer's  voice  was  im- 
\  proved,  after  removal  of  the  normal  tonsils"; 
when  Shakespeare  reports  pupils  whose  "voices 
have  suffered  from  faulty  operation";  when 
Sebastiani  states  that  "in  cases  of  enlargement  of 
the  tonsils,  while  excision  may  be  of  some  benefit 
to  the  voice  in  general,  it  may  not  be  of  any  bene- 
fit to  specialized  organisms  endowed  with  excep- 
tional and  valuable  voices.  In  these  uncommon 
conditions,  any  surgical  operation  whatsoever,  it 


PRINCIPLES  OF  TREATMENT  353 

matters  not  how  perfect,  can  cause  harm  to  the 
precious  instrument" ;  when  Lamperti,  31me. 
Cappiani,  Sehastiani,  Shakespeare,  Mme.  Mott, 
Mme.  Von  Klenner,  Mme.  Schumann-Heink, 
Bispham,  Hubbard,  Taylor,  Mme.  Everett, 
''have  personally  known  of  many  cases  in  which 
the  singer's  voice  was  impaired  after  removal  of 
the  tonsils";  when  Mme.  Adelina  Patti  (now 
Baroness  Cederstrom)  has  informed  me  that  the 
statements  of  Sir  Gordon  Holmes,  Lennox 
Browne  and  Emil  Behnke  and  others  are  false 
when  they  say  that  she  ever  "had  an  opera- 
tion done  on  her  throat,  either  to  remove  her  ton- 
sils, or  to  improve  her  voice  in  any  manner  what- 
soever'';  when  Von  Chiari,  Von  Schrotter,  Barth, 
Schmiegelow,  Brieger,  Goerke,  Frdnkel,  Groher, 
Von  Levinstein,  Schoenemann,  Escat,  Moure, 
Loewenherg,  Massei,  Semon,  Marage,  Ler- 
moyez,  Luhet-Barhon,  Luc,  Castecc,  Van  Bag- 
gen,  F.  E.  Miller,  Curtis,  Mackenzie,  Ross, 
Beverly  Robinson,  G.  B.  Rice,  Holmes, 
Mills,  Gleitsmann,  Gleason,  Hodenpyl,  C. 
H.  Knight,  Makuen,  A.  Coolidge,  Jr.,  Mac- 
Callum,  Casselberry,  Wood,  Lamperti,  Shake- 
speare, De  Reszke,  Santley,  Sebastiani,  Mine. 
Lehmann,  Mme.  Cappiani,  Mme.  Mott,  Sabatini, 
Mme.  San  Carola,  Mme.  Marchesi,  Charles  A. 
Rice,  George  A.  Sweet,  Mme.  Von  Klenner, 
Mme.  Clara  Kathleen  Rogers,  Fergusson,  Hub- 
bard, Townsend,  S.  S.  Curry,  Charles  A.  White, 
Bristol,  31  me.  Everett,  Taylor,  Mme.  Schumann- 
Heink,  Mme.  Nordica,  Mme.  Tetrazzini,  Mme. 
Fremstad,  Bispham  and  Bond,  declare  that  "nor- 
mal tonsils  should  never  be  removed";  when,  we 

24 


354  THE    TONSILS    AND    THE    VOICE 

review  the  diversified  opinions  of  the  most  emi- 
nent scholars,  thinkers  and  teachers,  of  both  the 
medical  and  voice  professions ;  when  we  hear  the 
sharp  criticisms  of  Frdnkel  and  Mine.  Lehmann, 
of  Lermoyez  and  Lampertij  of  Semon  and 
Marchesi,  of  Von  Levinstein  and  Sehastiani,  of 
Mackenzie  and  Bispham,  of  Mme.  Cappiani  and 
Mme.  Schumann-Heinkj  then  we  are  compelled 
to  admit  that  the  popularity  of  tonsillectomy 
lacks  authority,  and  that  the  treatment  of  the  ton- 
sils needs  to  he  tempered  with  scientific  modera- 
tion and  scientific  unity. 

Haymann  declares  that  ''the  great  majority 
of  deaths  caused  by  enucleation  are  not  reported/' 

Sir  Felix  Semon  (Diseases  of  the  Upper  Air 
Passages)  "maintains  that  the  frequency  with 
which  local  interference  is  advised  and  practiced 
nowadays  is  far  in  excess  of  actual  requirements; 
that  operations  are  performed  wholesale  where 
they  are  not  needed,  that  operative  proposals  are 
being  made  and  carried  out  on  an  extensive  scale 
on  the  basis  of  some  unproven  theory,  and  that 
the  operative  interference  often  enough,  is  unduly 
severe  and  protracted  in  proportion  to  the  small- 
ness  of  the  complaint  for  which  it  is  undertaken." 

"Not  every  little  bundle  of  adenoid  tissue  by 
chance  discovered  in  the  vault  of  the  pharynx 
must  needs  be  removed,  nor  ought  every  tonsil  to 
be  cut  which  slightty  projects  beyond  the  palatal 
arches." 

John  N.  3Iackenzie  {The  Massacre  of  The 
Tonsils)  says:  "The  mere  size  of  the  tonsil  is 
of  itself  no  indication  for  removal  except  it  be 
large  enough  or  diseased  sufficiently  to  interfere 


PRINCIPLES  OF  TREATMENT  355 

with  respiration,  speech,  or  deglutition,  in  which 
case,  it,  or  a  sufficient  portion,  should  be  taken 
away  without  delay.  A  large  tonsil  does  not 
mean  necessarily  a  diseased  tonsil,  nor  does  a 
small  tonsil  always  indicate  a  healthy  organ.  The 
tonsil  may  be  greatly  enlarged,  may  extend  far 
down  into  the  pharynx,  or  be  buried  deeply  in 
the  palatine  arcade,  and  yet  not  interfere  with 
the  well-being  of  the  individual.  Such  tonsils 
are  the  special  prey  of  the  tonsillectomist.  If 
they  are  not  interfering  with  function,  they  had 
best  be  left  alone,  for  they  are  doing  no  harm. 
The  change  in  anatomical  relations  after  opera- 
tion is  often  so  great  that  function  is  crippled 
more  after  their  complete  removal  than  it  was 
before.  Moreover,  it  occasionally  happens  that 
the  resurrection  of  a  'buried'  tonsil  is  followed  by 
the  burial  of  the  patient." 

"If,  in  infancy  and  childhood,  we  pay  more 
attention  to  the  neglected  nasal  cavities,  and  to 
the  hygiene  of  the  mouth  and  teeth,  we  will  have 
less  tonsil  disease  and  fewer  tonsil  operations." 

"In  the  permanent  removal  of  tonsil  disease, 
equally  good,  and  in  the  long  run  even  better,  re- 
sults may  be  obtained  in  a  large  percentage  of 
cases  by  measures  less  radical  than  those  usually 
employed  at  the  present  time.  Take  the  case  of 
recurring  quinsy.  In  this  condition,  it  has  been 
found  that  it  is  frequently  only  necessarj^  to 
thoroughly  slit  up  and  shrink  the  upper  lobe  of 
the  tonsil.  Most  quinsies  occur  in  this  situation 
and  the  destruction  of  that  part  of  the  tonsil  is  all 
sufficient  to  prevent  recurrence." 

"The  truth  is  slowly  hut  surely  dawning,  and 


356  THE    TONSILS    AND    THE    VOICE 

at  no  distant  day  will  irresistibly  emerge  into 
recognition  that  the  so-called  complete  enuclea- 
tion— the  chief  objection  to  which  is  that  it  can 
7iever  be  made  complete — except  in  individuals 
in  whom  the  organ  is  totally  diseased,  is  an  un- 
necessary operation  in  the  great  majority  of  cases 
in  which  it  is  at  present  done,  and  may  be  sup- 
planted by  many  other  methods  which  are  per- 
fectly safe  and  efficient  and  not  open  to  its  many 
serious  objections.  That  the  tonsil  has  some  im- 
portant mission  to  fulfil  is  shown  from  its  fre*- 
quent  re-appearance  after  enucleation — a  protest 
as  it  were — on  the  part  of  nature  against  the 
total  destruction  of  its  functions." 

"Enucleation  is  done  all  over  the  land  by 
operators  of  all  kinds,  and  if  the  truth  were 
known,  with  great  mortality.  Let  us  hope  that 
the  day  is  not  far  distant  when  not  only  the  pro- 
fession but  the  public  shall  demand  that  this 
senseless  slaughter  be  stopped." 

"The  tonsil  should  not  be  sacrificed  any  more 
than  any  other  organ,  without  convincing  evi- 
dence that  it  is  the  cause  of  the  disease  to  be 
removed." 

Swain:  "Even  in  adults  there  are  other  meth- 
ods of  bringing  about  a  satisfactory  and  safe 
condition  of  the  tonsils  besides  tonsillectomy. 
These  latter  methods  I  almost  universally  employ 
by  preference." 

Roe:  "Patients  sometimes  complain  more  of 
septic  trouble  around  the  neck  and  of  glandular 
swellings  after  the  tonsil  operation  than  before 
it." 

W.  K.  Simpson:  "There  may  occur,  always,  a 


PRINCIPLES  OF  TREATMENT  357 

filling  up  of  the  tonsillar  fossa  with  cicatricial, 
adenoid  and  connective  tissue,  and  from  this  there 
may  arise  an  interference  with  the  muscular 
action  of  the  velum,  which  would  be  just  as  harm- 
ful as  the  leaving  behind  of  a  small  portion  of 
the  tonsil." 

Watson  Williams  (Journal  of  Laryngology, 
October,  1910)  :  "In  rheumatism,  which  has 
been  ascribed  to  tonsillitis,  I  have  frequently 
found  the  tonsils  atrophied  or  absent.  I  do  not 
think,  therefore,  that  enucleation  is  the  best 
operation." 

Lambert  Lack  (Journal  of  Laryngology,  Oc- 
tober, 1910)  holds  that  "enucleation  should 
never  be  the  routine  operation.  The  need  of  get- 
ting every  crypt  away  is  exaggerated." 

Syme     (Journal    of    Laryngology,    October, 

1910)  states  that,  "Enucleation  is  not  necessary 
in  every  case.  What  should  be  done  with  the 
granulation  tissue  which  fills  up  the  fossa  after 
enucleation?  The  after  effects  of  enucleation 
are  more  severe  than  those  after  tonsillotomy." 

Dan  McKenzie  (British  Medical  Journal^ 
November  19,  1910) :  "One  would  be  very  cau- 
tious in  recommending  enucleation  to  a  profes- 
sional singer,  for  obvious  reasons." 

A.    Jacohi     (Medical    Record,    August    19, 

1911)  :  "Does  not  believe  that  operations  on  the 
tonsil  should  be  done  as  frequently  as  some 
seemed  to  think.  It  is  not  a  matter  of  indiffer- 
ence whether  the  capsule  is  removed  or  not.  We 
should  learn  that  infection  through  the  capsule  is 
rather  difficult ;  the  capsule  is  a  protection  to  the 
blood  and  lymph  circulation. 


358  II^E    TONSILS    AND    THE    VOICE 

"I  desire  to  emphasize  the  desirabihty  of  keep- 
ing the  nares  clean  both  before  and  after  opera- 
tion: if  there  were  greater  care  in  this  respect  so 
many  operations  on  the  tonsil  would  probably 
not  be  necessary." 

Escat  (Oto-Laryngologiqiie  Presse,  Belgian, 
No.  7  of  1910)  :  "Adenoid  tissue  is  not  neoplas- 
tic; why  then  be  so  bent  upon  extirpating  the 
tonsil  as  radically  as  if  it  were  a  cancer?  It  is  to 
be  feared  that  if  tonsillectomy,  following  the 
American  method,  becomes  very  common,  the 
cases  of  operative  hemorrhage  will  multiply  and 
that  the  good  reputation  of  tonsillectomy  will 
suffer  from  it." 

Scliijfers  (Oto-Laryngologique  Presse,  Bel- 
gian, No.  7  of  1910)  :  "When  it  concerns  the  set- 
ting forth  of  therapeutic,  and  above  all,  of  opera- 
tive conditions,  it  is  necessarj^  to  consider  the  nor- 
mal and  pathologic  state  of  an  organ." 

"Tonsillectomy  is  not  imposed,  and  is  not  jus- 
tified except  in  cases  of  malign  tumors  of  the 
tonsil.  The  tonsil  itself  is,  however,  very  rarely 
attacked  by  suppuration:  there  exist  certainly 
suppurative  follicles,  hut  the  interstitial  tissue 
itself  does  not  suppurate.  When  we  speak  of 
tonsillitis,  it  concerns,  in  the  immense  majority 
of  cases,  peritonsillitis." 

Cheval  (Oto-Laryngologique  Presse,  Belgian, 
No.  7  of  1910)  :  "If  it  is  evident  that  the  patho- 
logic tonsil  may  be  a  source  of  infection  and  has 
no  longer  the  power  of  coming  to  the  defense  of 
the  organism;  per  contra,  in  a  state  of  perfect 
health   and   under   ordinarv   circumstances,   the 


PRINCIPLES  OF  TREATMENT  359 

physiological  tonsil  has  for  its  function  the  as- 
sisting in  that  defense." 

Delsaucc  (Oto-Laryngologique  Presse,  Bel- 
gian^ No.  7  of  1910)  :  "Simple  hypertrophic  ton- 
sils are  rarely  accompanied  by  ganglionic  inva- 
sions of  the  neck." 

Grober  {Die  Tonsillen  als  Eintrittsspforten 
fur  Krankheitseneger,  hesonden  filr  den  Tuher- 
helhacillus)  :  "Many  authors  have  considered 
diseased  tonsils  as  more  liable  to  microbial  infec- 
tion than  healthy  ones.  If  that  is  truej  it  has  not 
been  proven/^ 

"The  best  prophylactic  measure  is  cleansing 
and  disinfection  of  the  mucous  membrane  of  the 
oral  cavity,  and  dentistry.  Besides,  medical  sci- 
ence shows  that  the  entrance  of  the  microbes  into 
the  system  does  not  always  produce  the  disease. 
It  is  important  how  strong  the  defensive  pro- 
cesses of  the  body  are.  Therefore,  infectious  dis- 
eases are  mostly  constitutional  diseases." 

Von  Chiari  {Die  Krankheiten  Des  Rachens, 
1903)  :  "I  would  like  to  call  attention  to  a  peculiar 
disturbance  of  the  voice.  One  does  observe  this 
in  elder  professional  singers  if  their  large  hyper- 
trophic tonsils  have  been  removed." 

"Although  it  is  rare  in  grown  people  that  the 
hypertrophy  of  the  tonsils  assumes  an  intense 
degree,  but  in  such  cases  the  tonsils  push  apart 
the  faucial  arches  and  stretch  them  very  much 
in  the  course  of  years.  The  muscles  of  the  fau- 
cial arches  become  insufficient,  while  the  faucial 
arches  remain  tense,  being  supported  by  the  big 
tonsils.  If  these  tonsils  are  removed  to  the  bot- 
tom of  the  sinus  tonsillaris,  the  faucial  arches  lose 


360  THE    TONSILS    AND    THE    VOICE 

their  support  and  their  muscles  cannot  contract 
to  keep  the  arches  tense.  Thus  for  the  singer 
the  equal  tension  of  the  walls  of  the  resonance 
tube  is  disturbed.  Enlarged  tonsils  which  pro- 
duce no  trouble  and  which  do  not  too  often  pro- 
duce inflammation  of  the  throat,  should  he  left 
alone.  Especially  in  elder  singers.  In  these 
cases,  the  only  thing  to  do  is  to  amputate  the  pro- 
tiniding  part,  but  never  to  extirpate  the  whole 
organ." 

Von  Levinstein  {Kritisches  zur  Frage  der 
Funktion  der  Mandeln,  Archiv  fiir  Laryngolo- 
gie,  23  Bd.  1  Heft.)  saj^s:  "There  is  no  doubt 
that  a  great  number  of  anginas  have  to  be  con- 
sidered as  a  primary  acute  infection  of  the  tonsils. 
Of  course,  the  tonsils  can  become  affected  secon- 
darily; as  following  endonasal  operation,  via  the 
blood  cun*ent,  etc." 

"The  possibility  of  primarj^  infection  is  con- 
ceded by  the  friends  of  the  protective  theorj^  only 
when  the  protective  mechanism  is  disturbed.  But 
that  according  to  the  protective  theory,  the  tonsils 
are  not  primarily  diseased,  but  secondarily  via 
the  blood  and  lymph  vessels  from  another  organ 
primarily  diseased." 

"That  the  latter  modes  of  infection  do  not  hap- 
pen rarely  I  have  conceded  and  mentioned  an- 
gina traumatica  after  operation  on  the  nose  as 
well  as  by  the  blood." 

"There  seems  to  be  no  doubt  that  the  tonsils 
are  very  often  diseased  primarily,  and  that  their 
frequent  secondary  infection  does  seem  to  he  ap- 
proved,* that  they  are  particularly  well  protected 
against  infections.'' 


PRINCIPLES  OF  TREATMENT  361 

"I  would  like  to  mention  the  galvanocaustic 
treatment  of  the  tonsils  as  a  means  of  protection 
against  the  frequent  affections  of  angina.  This 
treatment  apparently  makes  the  surface  of  the 
tonsils  more  resistible  against  infectious  germs. 
This  treatment  is  the  best  remedy  against  re- 
lapsing anginas." 

"Winslow  claims  that  the  tonsils  are  a  menace 
to  the  system.  I  rather  believe  that  the  infection 
theory  is  too  extreme.  But  if  the  tonsil  offers 
less  resistance  to  the  entrance  of  infections  than 
its  neighborhood,  we  are  still  not  entitled  to  talk 
of  a  danger  to  the  system  from  this  organ.  And 
if  Bosworth,  Hendelssohn  and  others  come  to  the 
conclusion  that  the  tonsil  as  a  continuous  danger 
for  the  body  should  in  persons  be  totally  eradi- 
cated, I  cannot  come  to  the  same  conclusion,  for  if 
I  know  of  an  organ  that  easily  becomes  infected, 
this  organ  should  not  be  destroyed,  but  we  should 
try  to  perfect  it  as  much  as  possible  against  the 
danger  of  infection  which  in  the  tonsil  is  not  so 
difficult  to  do.  We  should  decrease  the  micro- 
organisms of  the  nose  and  throat  by  keeping  the 
nose  and  throat  clean." 

"The  healing  of  angina  relapses  after  a  care- 
ful treatment  of  the  nose  is  caused  through  re- 
ducing the  infectious  germs  present  in  the  nose. 
Also  throat  antiseptics  will  reduce  the  number 
of  micro-organisms  in  the  throat.  Another 
remedy  to  prevent  the  infection  of  the  tonsils  is 
a  systematic  hardening  of  the  body.  Hardened 
persons  contract  colds  less  easily.  Therefore, 
next  to  the  care  of  the  nose  and  throat,  general 


362  THE    TONSILS    AND    THE    VOICE 

systematic  hardening  of  the  organism  is  the  best 
protection  against  infection  of  the  tonsils." 

"When  the  tonsils  become  diseased  in  spite  of 
the  above  means,  therapie  has  to  become  more 
energetic,  by  treating  the  tonsils  locally,  mainly 
by  galvano-cautery,  which  makes  these  organs 
more  resistible.  It  makes  the  entrance  of  germs 
more  difficult.  By  this  treatment,  we  do  not  in- 
tend the  radical  destruction  of  the  tonsils,  as 
only  the  surface  is  healed.  We  desire  to  make 
the  organ  more  resistible.  We  want  by  our  pro- 
cess to  cure  and  not  to  destroy,  as  do  the  be- 
lievers in  the  extreme  infection  theory.  Such  a 
total  and  lasting  destruction  of  the  tonsillar 
tissue,  is,  as  Goerke  has  proved,  absolutely  im- 
possible, for  it  regenerates  always.  Therefore, 
the  tonsils,  as  organs  easily  infected  must  be 
particularly  protected  against  the  possibility  of 
infection,  by  reducing  as  much  as  possible  the 
infectious  germs  in  the  nose  and  throat;  by 
hardening  of  the  whole  organism;  and  in  cases 
where  these  remedies  are  insufficient,  galvano- 
cautery  of  the  tonsils  should  be  used/' 

"If  the  organ  is  in  the  condition  of  acute  in- 
fection, we  should  consider  whether  the  disease 
is  local  or  general.  If  local,  we  will  get  good  re- 
sults by  local  means;  if  general  we  will  have  to 
treat  the  general  infection." 

"I  cannot  approve  of  eradicating  the  tonsils. 
If  I  am  told  that  the  tonsils  have  no  distinct 
function,  and  on  the  other  hand  become  easily 
diseased  and  therefore  not  the  slightest  cause 
exists  to  save  these  organs,  I  must  say  that  it 
is   not   impossible  that   the   tonsils   have   a   dis- 


PRINCIPLES  OF  TREATMENT  363 

tinct  physiological  function  only  so  far  we 
have  no  proof  for  it.  And  then  even  if  it  were 
sure  that  the  tonsils  had  no  distinct  function,  I 
would  not  give  up  my  conservative  standpoint. 
For  if  an  organ  of  our  body  and  even  one  which 
is  not  necessary  for  the  existence  of  the  organ- 
ism should  prove  less  resistible  than  other 
organs,  this  circumstance  does  not  at  all  entitle 
us  to  destroy  this  organ.  Our  task  should  be 
to  prevent  the  disease  of  this  organ  by  reducing 
the  infectious  germs  and  strengthening  the 
organ  through  local  and  general  means.  Who 
of  us  for  the  reason  only  that  because  he  knows 
that  his  tonsils  will  become  easily  infected  would 
allow  his  healthy  tonsils  to  be  eradicated;  in 
other  words,  that  he  submit  to  an  operation 
which  is  absolutely  not  simple,  and  which  be- 
sides can  never  be  completely  done  as  the  ade- 
noid tissue  is  continuously  regenerated.'' 

Von  Levinstein  {Archiv  fur  Laryngologie  und 
Rhinologie,  Bd.  XXIV,  Heft  2,  1911).  ''In  the 
treatment  of  chronic  tonsillitis  and  angina  accord- 
ing to  the  method  which  I  have  described,  there 
will  rarely  be  occasion  to  resort  to  radical  mea- 
sures, for  example,  tonsillectomy." 

''Tonsillectomy,  the  object  of  which  is  not  to 
heal  microscopically  and  macroscopically  diseased 
portions  of  the  organ  but  to  remove  it  root  and 
branch,  should  never  be  resorted  to  before  it  has 
been  demonstrated  that  the  infectious  disease  of 
the  tonsil  cannot  be  overcome  in  any  other  way. 
My  method  of  using  galvano-cautery  is  not  only 
to  be  considered  a  conservative  method  in  that  in 
nearly  all  cases  only  a  portion  of  the  organ  is  at- 


364  THE    TONSILS    AND    THE    VOICE 

tacked  and  its  structure  altered,  hut  that  in  near- 
ly all  cases  recovery  is  brought  about  in  a  much 
shorter  time."  ' 

"The  most  frequent  source  of  quinsy,  by  far, 
from  which  people  suffer,  is  the  upper  lobe  of  the 
tonsil.  In  a  great  many  cases,  it  is  often  un- 
necessary to  do  anything  more  than  to  properly 
free  the  upper  lobe,  thoroughly  slit  it  up,  and 
take  care  of  it.  Where  only  a  part  of  the  tonsil 
is  affected,  as  for  example,  the  upper  part,  or 
only  a  single  follicle,  then  only  that  part  should 
be  treated." 

''Finally,  in  all  bad  cases,  according  to  my  ex- 
perience, before  resort  is  had  to  tonsillectomy,  an 
attempt  should  be  made  to  cure  by  the  use  of 
galvano-cautery  according  to  the  method  I  have 
just  described.  After  that,  in  particidarly  ob- 
stinate cases,  which  I  am  convinced  will  be  the 
exception,  tonsillectomy  may  be  indicated.  And 
I  hope,  in  view  of  these  investigations  and  state- 
ments, the  radical  removal  by  operation  of  an 
organ,  the  uselessness  of  which  to  the  general  sys- 
tem has  by  no  means  been  proved,  will  be  less  fre- 
quently performed."' 

Von  Lendrt  (Archiv  fur  Laryngologie 
und  Rhinologie,  Band  XXI,  Heft.  3,  1909)  : 
"(1)  Material  that  has  forced  its  way  into  the 
nasal  cavity  can  reach  the  tonsil  via  the  lymph 
channel.  Hence  it  follows,  and  has  been  proved 
by  clinical  experience,  that  infectious  material 
from  the  nose  reaches  the  tonsil  via  the  lymph 
channel  and  may  start  inflammatory  processes 
there." 

"(2)   It  confirms  A.  3Iost's  contention  con- 


PRINCIPLES  OF  TREATMENT  365 

cerning  the  course  of  the  lymph  current  in  the 
nose  and  throat,  which  he  arrived  at  through  his 
anatomical  studies." 

"(3)  It  follows  from  our  experiments  that 
foreign  bodies  which  get  into  the  tonsils  are  to 
some  extent  expelled  therefrom  toward  the  sur- 
face of  the  tonsil." 

"(4)  There  is  a  very  intimate  connection  be- 
tween the  lymph  vessels  of  the  two  tonsils.  For 
an  injection  in  one  side  distributes  itself  not  only 
to  the  corresponding  tonsil  but  also  to  the  one  on 
the  other  side." 

It  therefore  makes  no  difference  how  clean 
you  keep  the  surface  of  the  tonsil,  septic  material 
may  pass  from  one  tonsil  to  the  other,  underneath 
the  surface,  via  the  lymph  channels.  This  fact 
gives  one  a  very  different  understanding  from 
the  usually  accepted  idea  that  the  tonsils  are  com- 
monlj^  affected  merely  from  matter  soaking  into 
them  from  the  mouth. 

Sir  Felix  Semon  says  that,  "A  thoroughly  suf- 
ficient operation  is  by  no  means  identical  with 
'complete  removal'  of  the  gland.  I  have  from 
the  time  of  my  earliest  operations,  endeavored  to 
take  off  so  much  of  the  tonsils  that  they  become 
at  least  reduced  to  the  maximum  of  their  normal 
size,  that  is,  that  they  do  not  project  beyond  the 
palatine  arch.  In  many  hundred  cases  of  tonsil- 
lectomy in  my  own  practice  I  have  but  once  seen 
a  considerable  re-enlargement  take  place.  I 
recommend  surgical  interference  with  enlarged 
tonsils  only  when  they  cause  serious  symptoms 
and  not  merely  on  account  of  the  enlargement  per 
se.      Comparatively   large    tonsils    in   a  roomy 


366  THE    TONSILS    AND    THE    VOICE 

pharynx  are  no  doubt  much  less  mischievous  per 
se,  than  most  smaller  ones  in  a  naturally  very 
narrow  throat.  I  have  no  doubt  that  tonsils  can 
he  equally  well  removed  by  very  different  meth- 
ods. I  consider  total  enucleation  not  only  dan- 
gerous, hut  also  generally  superfluous" 

The  limitations  of  a  language  hinder  the 
spread  of  scientific  konwledge.  It  is  a  matter  of 
regret  that  monographs  of  great  value  lie  buried 
in  some  foreign  language,  interesting  only  to  a 
few,  inaccessible  to  those  who  read  English  only, 
and  are  never  translated  because  of  no  remunera- 
tive value  to  a  publisher. 

For  instance,  I  cite  the  work  of  Marage,  direc- 
itor  of  the  course  of  lectures  at  the  Sorhonne,  than 
whom,  in  his  line,  there  is  no  higher  authority  in 
France,  nor  even  in  the  world. 

In  his  extraordinary  monograph  on  ''Traite- 
ment  Medical  des  Vegetations  Adenoides,"  he 
says:  "I  have  waited  seven  years  before  re- 
vising this  work  with  a  view  of  having  the  results 
certain;  and  I  can  rest  my  statistics  upon  more 
than  five  hundred  cases  cared  for  by  this 
method." 

"With  this  medical  treatment,  we  do  not  have 
to  fear  the  relapses  which  are  so  frequent  after 
an  operation." 

"This  method  is  exempt  from  all  danger." 

"We  think  that  medical  treatment  can  replace 
the  surgical  method  in  ninety-two  per  cent  of  the 
cases  observed  among  our  patients." 

Marage's  statements  are  remarkable  and  de- 
serve profound  consideration.  His  monograph 
is  certainly  the  most  scientific  treatise  upon  the 


PRINCIPLES  OF  TREATMENT  367 

subject  that  has  appeared  in  any  language.  I 
have  found  no  mention  of  it  anywhere.  I  fully 
endorse  and  constantly  use  his  method. 

Another  monograph,  very  complete  and  of 
great  scientific  value,  is  that  of  Marage,  entitled 
"Quand  et  Comment  Traiter  les  Arnygdales 
Hypertrophiees"  in  which  he  declares  that : 

"There  is  not  one  treatment  for  hypertrophy 
of  the  tonsils:  there  are  many:  it  is  for  the  sur- 
geon to  know  which  to  choose.  The  better  pro- 
ceeding will  be  that  which  gives  the  better  re- 
sult." 

"It  is  necessary  to  place  ourselves  in  those  con- 
ditions where  we  have  never  to  fear  a  fatal  issue." 

"It  is  of  the  first  importance  to  completely 
withhold  all  anaesthesia,  no  matter  what  it  be, 
unless  the  conditions  are  very  exceptional." 

"The  second  important  matter  is  to  employ 
different  methods,  according  to  the  nature  of  the 
case:  a  certain  proceeding  perfect  for  an  infant 
is  dangerous  with  an  adult;  another,  applicable 
to  a  docile  patient,  is  impossible  with  a  child  who 
fights  or  struggles." 

"Suinming  all  up,  there  are  indications  and 
contra-indications  innmnerahle,  which  it  is  neces- 
sary to  take  well  into  account" 

The  teaching  of  Marage  is  eminently  sound 
and  successful. 

"If  by  chance  there  is  a  secondary  hemorrhage, 
it  may  be  easily  arrested,"  he  says,  "with  perchlo- 
ride  of  iron,  the  thermo-cautery,  or  the  galvano- 
cautery,  or  finally,  with  the  forceps." 

Calcium  lactate,   also,  is  now  used  by  many 


368  THE    TONSILS    AND    THE    VOICE 

operators  to  assist  in  controlling  or  preventing 
hemorrhages  of  the  upper  air  tract. 

Von  Levinstein  (University  of  Berlin),  than 
whom  there  is  no  higher  authority  in  the  world 
on  the  subject,  in  a  most  exhaustive  and  convin- 
cing communication,  "^Zur  Behandlung  der  Ton- 
sillitis Chronica  und  Angina  Hahitualis/'  in  the 
Arcliiv  filr  Laryngologies  Heft  2,  Berlin,  1911, 
says:  "If  a  ;par^  of  the  tonsil  is  diseased,  as  for 
example  a  single  follicle,  then  only  that  part 
should  be  treated,  not  the  entire  organ." 

Von  Chiari  [University  of  Vienna) ,  who  ranks 
as  second  to  no  other  authority  upon  the  surgery 
of  the  throat,  in  his  work  entitled  ''Die  Krank- 
lieiten  des  Rachens/^  1903,  advises  against  the  re- 
moval of  enlarged  tonsils  in  elder  professional 
singers.  The  larger  the  tonsil^  the  stronger  his 
reasons  for  non-interference. 

Barth  [University  of  Leipzig)  says:  "I  do 
not  remove  normal  or  slightly  hypertrophic  ton- 
sils (which  do  not  cause  pathological  disturb- 
ances). If  one  wanted  to  do  that  one  would 
have  to  perform  in  any  normal  man  a  number  of 
prophylactic  operations." 

Loexj^enherg  (Berlin)  says:  "I  disapprove  of 
operations  upon  normal  tonsils  in  all  cases." 

Lermoyez  (Paris)  says:  "I  consider  that  the 
normal  tonsils  are  organs  that  must  he  respected. 
One  should  never  remove  the  human  organs :  not 
more  a  normal  tonsil  than  a  healthy  tooth  or  a 
healthy  eye!" 

Sir  Felix  Semon  (London)  has  constantly  re- 
iterated his  views  that  "A  thoroughly  sufficient 
operation  is  by  no  means  identical  with  'complete 


PRINCIPLES  OF  TREATMENT  359 

removal'  of  the  gland.  Tonsils  can  be  equally 
well  removed  by  very  different  methods.  I  con- 
sider total  enucleation  of  the  gland  not  only  dan- 
gerous, but  also  generally  superfluous." 

Escat  (Toulouse)  states  that:  "It  is  not  neces- 
sary, in  my  opinion,  to  set  one's  heart  upon  com- 
pletely extracting  all  of  the  tonsillar  tissue,  as 
various  American  confreres  proposed.  The  ton- 
sil is  not  a  cancer !" 

Schiffers  {La  Presse  Oto-Laryngologique, 
Beige,  No.  7,  1910),  says:  "When  it  concerns 
the  setting  forth  of  therapeutic,  and  above  all,  of 
operatory  conditions,  it  is  necessary  to  consider 
the  normal  and  pathologic  state  of  an  organ. 

"Tonsillectomy  is  not  imposed,  and  is  not  justi- 
fied, except  in  cases  of  malign  tumors  of  the 
tonsil." 

Gleitsmann  (New  York)  in  an  article  on 
'''Treatment  of  Chronic  Affections  of  the  Tonsil, '' 
New  York  Medical  Journal,  September  4,  1897 ; 

Jacohi  (Colunihia  University)  in  a  mono- 
graph on  the  "Phases  in  the  Development  of 
Therapy,''  Medical  News,  November  4,  1905; 
and  in  an  article  on  ''The  Tonsil  as  a  Portal  of 
Microbic  and  Toxic  Invasion,"  Archives  of  Pedi- 
atrics, July,  1906 ; 

Swain  (Yale  University) ,  in  a  monograph  on 
"Are  the  Tonsils  a  Menace  or  a  Protection?" 
Annals  of  Otology,  Rhinology  and  Laryngology, 
September,  1911; 

Mackenzie  (Johns  Hopkins  University)  in  his 
article  on  "Abuses  m  Intranasal  Surgery,"  New 
York  Medical  Journal,  January  28,  1905;  and 
again  in  his  monograph  on  "The  Massacre  of  the 

25 


370  THE    TONSILS    AND    THE    VOICE 

Tonsil*'    Maryland    Medical    Journal,    June, 

1912; 

are  in  line  with  the  teachings  of  Marage,  Von 

Levinstein,  Von  Chiari,  Barth,  Sir  Felix  Semon, 

Escatj  Schifers,  Loewenherg  and  Lermoyez. 

It's  a  monstrous  thought  that  permits  an  in- 
telligent and  educated  surgeon  to  destroy  an  or- 
gan of  the  human  body,  the  physiology  of  which 
he  does  not  know. 

It's  a  fine  thought  of  Sir  Morell  Mackenzie, 
when  he  says:  "All  I  claim  for  science  is  a  right 
of  veto  against  methods  which  are  physically 
hurtful." 

Methods  of  practice  that  have  no  foundation, 
no  bottom,  no  authority,  are  generally  hurtful. 

Mar  age.  Von  Levinstein,  Von  CJiiari,  Barth, 
Sir  Felix  Semon,  Escat,  Schifers,  Loewenherg, 
Lermoyez,  Gleitsmann,  Jacohi,  Mackenzie  and 
Swain  are  men  of  great  practical  experience. 
The}^  pick  their  cases  and  select  their  treatment. 
They  are  great  authorities.  They  oppose  the 
routine  enucleation  of  the  tonsil.  And  routine 
enucleation  is  also  opposed  hy  the  entire  voice 
profession. 

Upon  what  foundation,  what  bottom,  what 
authoritj^,  rests  the  practice  of  enucleation?  I 
have  sought  assiduously  for  information. 

Charles  M.  Robertson  (Chicago)  in  The 
Journal  of  the  American  3Iedical  Association, 
August  28,  1909,  says:  "If  the  tonsil  in  a  ?2or- 
mal  state  is  removed  i?i  toto  there  is  no  disastrous 
after  effect.  On  the  contrary,  the  individual  is 
improved  in  health." 

This  plea  for  the   destruction    of  a   natural 


PRINCIPLES  OF  TREATMENT  37 1 

human  organ  stands  alone!  unparalleled  in  the 
annals  of  medical  literature. 

Operators  who  remove  the  tonsils  as  a  matter 
of  routine,  generally  deny  to  these  organs  any 
useful  function.  They  are  willing  to  destroy  pos- 
sible values,  of  which  they  admit  they  are  igno- 
rant. On  the  contrary,  I  have  presented  the  evi- 
dence of  men  who  attest  the  value  of  the  tonsils, 
and  with  their  knowledge,  they  refuse  to  destroy 
these  organs. 

It  is  no  doubt  true  that  every  organ  has  some 
physiological  function. 

Before  permitting  the  tonsil  to  he  removed,  ab- 
solute proof  should  be  demanded  that  the  disease 
which  affects  the  organ  cannot  be  cured  by  some 
reasonable  method  of  treatment.  Enucleation  is 
not  a  method  of  treatment.  Tonsillectomy  is 
destruction.  And  destruction  is  not  treatment. 
Ordinary  scientific  acumen  will  resent  a  general 
treatment  for  the  varied  affections  of  the  tonsils. 
You  have  no  right  to  enucleate  an  eye  for  a 
simple  disease  of  the  cornea,  nor  on  the  occur- 
rence of  strabismus.  Neither  have  you  any  right 
to  enucleate  a  tonsil  just  because  one  or  two  of 
its  follicles  are  diseased.  The  principle  is  the 
same. 

A  correct  differential  diagnosis;  a  positive 
determination  of  etiologic  and  pathologic  factors 
are  essential  to  a  reasonable  prognosis  and  a  sound 
method  of  treatment.  There  should  be  principles 
of  treatment  to  govern  the  therapy  of  the  tonsil. 
The  principles  may  apply  to  (1)  Primary  Af- 
fection; (2)   Secondary  Affection;  (3)   General 


372  THE    TONSILS    AND    THE    VOICE 

Affection;  (4)   Reflex  Affection;  (5)   Mechani- 
cal Affection;  (6)   Hyperplastic  Affection. 

(1)  Primary  Affection.  Starts  in  the  mouth, 
and  affects  chiefly  the  fossulae.  Requires  free 
exposure  of  the  fossular  surface,  drainage,  and 
hardening  treatment  to  render  the  surface  more 
resistible  to  bacterial  irritation.  The  whole  ton- 
sillar surface  may  require  treatment  to  make  it 
more  resistible;  aerosuction,  galvano-cautery, 
sterilization,  etc. 

If  the  tonsil  has  a  protective  physiological 
function,  then  it  is  a  scientific  blunder  to  enu- 
cleate the  organ.  It  has  not  been  proved  that  the 
tonsil  has  not  a  protective  function. 

If  the  tonsil  has  a  protective  function,  and  the 
organ  becomes  diseased,  then  we  should  save  as 
much  as  possible  of  the  tonsil  that  we  may  save 
as  much  as  possible  of  its  function. 

( 2 )  Secondary  Affection.  Arises  via  the  lym- 
phatic channels,  chiefly  from  the  nose.  If  the  in- 
fection is  thus  secondary,  via  the  lymphatic  chan- 
nels, then  the  tonsil  should  not  be  enucleated,  but 
the  disease  in  the  nose  requires  treatment. 

(3)  General  Affection.  Occurs  via  the  blood, 
and  is  symptomatic  of  general  blood  disease. 
The  infection  of  the  tonsil  from  the  blood, 
Frdnkel  states,  has  not  received  the  consideration 
which  it  deserves.  If  the  infection  of  the  tonsil 
is  symptomatic  via  the  blood  vessels  of  general 
blood  disease,  then  the  tonsil  should  not  be  enu- 
cleated, but  the  disease  of  the  blood  requires 
treatment. 

(4)  Reflex  Affection.     Frequently  associated 


PRINCIPLES  OF  TREATMENT  373 

with  dental  caries,  disease  of  the  gums  about  the 
necks  of  the  teeth,  etc. 

Reflex  afl'ections  of  the  tonsil  have  never  been 
considered  by  medical  writers. 

If  the  disease  of  the  tonsil  is  reflex  from  dental 
caries,  etc.,  then  the  tonsil  should  not  be  enu- 
cleated, but  the  teeth  should  be  treated. 

(5)  Mechanical  Affection.  This  form  of  af- 
fection is  common  among  voice  users  and  has  so 
far  met  with  little  or  no  consideration  by  medical 
writers.  If  the  tonsil  is  diseased,  or  enlarged 
through  mis-use  of  the  voice,  then  the  organ 
should  not  be  enucleated,  but  the  voice  should  be 
treated  by  a  voice  specialist  or  voice  trainer. 

What  should  a  parent  do,  with  a  child  whose 
tonsils  are  troublesome,  or  enlarged? 

He  should  obtain  the  advice  of  an  experienced 
physician,  of  one  who  is  able  and  willing  to  make 
a  thorough,  discriminative  diagnosis  to  ascertain 
whether  the  trouble  with  the  tonsil  is  a  primary 
affection,  secondarj^,  sj^mptomatic,  reflex,  me- 
chanical or  hyperplastic ;  of  one  who,  after  having 
learned  the  character  of  the  trouble,  will  then  do 
enough  investigating  to  learn  the  sjJecial  cause  in 
the  particular  case  m  hand,  whether  it  arises  from 
disease  or  discharge  in  the  nose,  or  disease  in  the 
blood,  or  bad  teeth,  bad  gums,  bad  stomach,  etc., 
which  cause,  upon  receiving  proper  attention, 
will  probably  cure  the  tonsil  trouble. 

What  should  an  adidt  do  when  his  or  her  ton- 
sils are  troublesome  or  enlarged? 

He  or  she  should  seek  a  physician  who  is  old 
enough  and  conservative  enough  to  be  familiar 
with  all  the  causes  that  lead  to  tonsil  affections. 


374  THE    TONSILS    AND    THE    VOICE 

and  who  is  both  able  and  mlling  to  remove  the 
cause  and  remedy  the  trouble. 

What  should  a  voice  user  do,  whose  tonsils  give 
trouble  ? 

Singers,  public  speakers  and  teachers  must  he 
exceedingly  cautious  in  what  they  do.  Think 
well  before  doing  anything,  and  then,  be  con- 
servative. Go  to  the  experienced  laryngologist, 
go  to  the  singing  master,  go  to  the  teacher  of  elo- 
cution, consult  these  three,  they  go  together. 

I  have  given  you  the  evidence  of  Von  Chiari — 
there  is  no  higher  medical  authority — that  ''great- 
ly enlarged  tonsils  in  elder  professional  singers 
should  NEVER  be  removed.'' 

I  have  given  you  the  testuxiony  of  Lamperti — 
there  is  no  higher  singing  authority — that  ''in 
almost  all  cases,  in  the  fifty  years  of  his  teaching, 
after  removal  of  the  tonsils  the  voice  is  m- 
jured,  often  beyond  remedy." 

I  have  given  you  the  evidence  of  Sebastiani, 
"that  if  excision  is  of  use  in  cases  of  hypertrophy 
to  avoid  greater  damage,  it  may  be  of  some  bene- 
fit to  the  voice  in  general,  but  to  specialized  or- 
ganisms, endowed  with  exceptional  and  valuable 
voices,  then,  in  these  uncouunon  conditions  any 
surgical  operation  whatsoever,  it  matters  not  how 
perfect,  can  harm  the  precious  instrument." 

The  choice  of  treatment  must  always  be  delib- 
erate, and  always  exactly  fitted  to  the  precise  re- 
quirement of  each  and  every  patient.  He  who 
does  not,  or  who  cannot,  make  a  defijiite  diag- 
nosis, deserves  to  be  eliminated  from  considera- 
tion as  an  expert  in  scientific  and  artistic  laryn- 
gology. 


PRINCIPLES  OF  TREATMENT  375 

Enucleation  of  the  tonsil  is  not  a  method  of 
treatment.  Enucleatio7i  is  destruction.  To  de- 
stroy is  not  to  treat. 

If  the  tonsil  has  any  physiological  function; 
if  it  has  an  internal  secretion,  as  suggested  by 
Masini  and  Shurly;  if  it  has  a  secretion  valu- 
able to  health  of  the  organism,  and  favorable  to 
the  growth  of  the  skeleton,  as  taught  by  Allen 
and  Escat;  if  it  possesses  the  function  of  phagocy- 
tosis, as  claimed  by  Metchnikoff  and  others ;  if  it 
is  a  lymphatic  node,  a  lymphatic  filter  for  nasal 
secretions,  as  proved  by  Von  Lendrt  and  others; 
if  most  diseases  of  the  tonsil  are  secondary  to  in- 
fections in  the  nose,  as  accepted  by  Frdnkel,  Von 
Levinstein  and  others ;  if  diseases  of  the  tonsil  are 
sometimes  symptomatic  of  constitutional  blood 
diseases,  as  all  authorities  admit ;  if  diseases  of  the 
tonsil  are  sometimes  due  to  reflexes  from  dental 
caries,  etc.;  if  the  tonsil  is  sometimes  diseased, 
and  enlarged,  from  mis-use  of  the  voice,  as  taught 
by  Van  Baggen,  Escat,  Casteoc,  Miller,  Garcia, 
Tosi,  Rice  and  others ;  if  it  is  essential  in  contrib- 
uting to  the  good  singing  tone,  as  claimed  by 
Lamperti,  Mme.  Cappiani,  Bispham  and  others; 
if  its  removal  always  impairs  the  singing  voice, 
as  declared  by  Loewenberg,  Sehastiani  and 
others ;  if  it  is  a  buffer  organ  as  3Ime.  Cappiani 
thinks;  if  it  has  mechanical  functions,  then, 
under  any  of  these  circumstances,  the  needless 
destruction  of  the  oi^gan  is  a  surgical  blunder. 

Before  permitting  the  tonsil  to  be  destroyed, 
please  remember  that  it  is  a  natural  organ,  pos- 
sessing a  normal  histologic  structure  which  the 
microscope  can  positively  determine;  that  this 


376  THE    TONSILS    AND    THE    VOICE 

tonsil  has  many  features  not  possessed  by  any 
other  bodj'-  in  Waldeyers  tymphatic  ring;  that 
no  lymphatic  sinuses  exist  around  the  tonsil ;  that 
the  immediate  neighborhood  of  the  tonsil  is  infe- 
rior in  regard  to  facilities  for  absorption  to  the 
pharynx  at  some  distance;  that  the  tonsil,  in  a 
normal  condition,  as  Hodenpyl  proved,  absorbs 
neither  liquid,  nor  solid  particles,  from  the  oral 
cavity ;  that  in  cases  of  diphtheria  where  the  mem- 
brane is  limited  to  the  tonsil,  Jacohi  has  repeat- 
edly proved  that  there  is  very  little,  or  no,  absorp- 
tion of  the  toxin;  that  the  external  deep  surface 
of  the  tonsil  is  encased  in  a  fibrous  sheath  con- 
taining muscular  fibres  derived  from  the  superior 
constrictor  of  the  pharjmx;  that  the  tonsil  con- 
tains a  system  of  closed  lymphatic  canals,  which 
do  not  open  into  connective  tissue,  as  proved  by 
Jletterer,  Krause,  Labhe  and  Vo7i  Levinstein; 
that  Von  Lendrt  has  proved  the  existence  of  a 
direct  communication  between  the  lymphatic  ves- 
sels of  the  nose  and  of  the  faucial  tonsils;  that 
Von  Lendt^t  has  also  shown  the  existence  of  an 
intimate  connection  between  the  two  faucial  ton- 
sils ;  that  Poli  states  that  the  lymphatic  regions  of 
the  two  nostrils  communicate  with  each  other  by 
anastomatic  branches  which  at  the  back  surround 
the  free  edge  of  the  septum  and  at  the  front, 
though  to  a  less  degree,  hj  vessels  which  pierce 
the  septal  cartilage;  that  the  tonsil  is  peculiarly 
situated  amidst  a  framework  of  active  muscles. 

The  voice  profession  must  hear  in  mind  the 
teaching  of  Voi7  Cliiari  that  the  removal  of  the 
enlarged  tonsils  in  elder  professional  singers  per- 
manently injures  the  voice ;  that  Richard  Loewen- 


PRINCIPLES  OF  TREATMENT  377 

herg  knows  of  cases  in  which  the  removal  of  nor- 
mal tonsils  has  caused  permanent  detrimental 
eiFects  to  the  voice,  and  that  he  knows  of  no  case 
in  which  a  singer's  voice  was  improved,  and  that 
he  disapproves  of  the  removal  of  normal  ton- 
sils in  all  cases ;  that  Lamperti,  Mme. '  Cappiani, 
Van  Baggen,  Hubbard,  and  Bispham  state  that 
the  removal  of  the  tonsil  interferes  with  the  modu- 
lation of  tone;  that  Sehastiani  states  that,  while 
excision,  in  cases  of  hypertrophy,  may  he  of  some 
benefit  to  the  voice  in  general,  it  may  he  of  no 
henefit  to  specialized  organisms  endowed  with  ex- 
ceptional and  valuahle  voices.  But  in  these  un- 
common conditions — specialized  organisms  with 
exceptional  and  valuahle  voices — any  surgical 
operation  whatsoever,  it  matters  not  how  perfect, 
can  cause  harm  to  the  precious  instrument;  that 
Sehastiani  and  Mme.  Schumann-Heink  declare 
that  after  enucleation  the  voice  has  been  dam- 
aged and  sometimes  entirely  lost;  that  Shake- 
speare reports  pupils  whose  voices  suffered  from 
faulty  operation;  that  De  Reszke  knew  of  only 
one  case  among  all  his  pupils  in  whom  the  tonsils 
were  removed;  that  Van  Bag  gen  advised  the 
removal  of  tonsils  in  only  two  cases  in 
eight  years;  that  Sahatini  has  only  twice  ever 
recommended  the  operation;  that  Mme.  Lilli 
Lehmann  and  Mme.  San  Carola  advise  against 
the  removal  of  anything  from  a  singer's  throat; 
that  Garcia,  Mme.  Viardot-Garcia,  JLaviperti, 
Mme.  Cappiani,  and  Mme.  Vo7i  Klenner  vigor- 
ously object  to  any  operation  on  the  tonsils  simply 
to  improve  the  voice ;  that  Lamperti,  Loewen- 
herg,  Mme.  Cappiani,  Mme.  Mott,  Sir  Charles 


378  THE    TONSILS    AND    THE    VOICE 

Santley,  Mme.  Von,  Klenner,  George  Sweet, 
Charles  A.  Rice,  Mme.  Nordica,  Mme.  Tetraz- 
zini,  Mme.  Schumann- Heink,  Mme.  San  Carola, 
Miss  Cecelia  Winter,  Bond,  Bispham,  Hubbard, 
Townsend,  Taylor,  have  never  known  of  a  case 
in  which  the  singer's  voice  was  improved  after 
the  removal  of  normal  tonsils ;  that  Loewenberg, 
Lamperti,  Sebastiani,  Shakespeare,  Mme.  Cap- 
piani,  Mme.  Mott,  Mme.  Von  Klenner,  Mme. 
Schumann-Heink,  Mme.  Everett,  Bispham, 
Hubbard,  and  Taylor  have  known  of  cases  in 
which  the  voice  was  impaired  after  the  removal 
of  the  tonsils ;  that  the  statements  of  Morell  Mac- 
kenzie, Lennox-Browne,  Emil  Behnke,  and  Gor- 
don Holmes,  that  Mme  Pattis  tonsils  were  re- 
moved and  that  her  voice  was  improved  thereby, 
are  flatly  contradicted  by  Mme.  Patti;  that  the 
tonsils  assist  in  the  mechanism  of  the  voice,  as- 
taught  by  Lamperti,  Mme.  Cappiani,  Van  Bag- 
gen,  Hubbard  and  others;  that  the  removal  of  the 
tonsils  interferes  with  the  voice  mechanism;  that 
all  voice  authorities  are  opposed  to  the  removal 
of  the  normal  tonsils;  that  after  removal  of  the 
tonsils  the  voice  is  often  impaired  beyond  rem- 
edy {Lamperti)  ;  have  always  found  a  lack  of 
sweetness  in  the  tone  quality — and  difficulty  in 
supporting  the  tone  in  certain  registers  {Mme. 
Von  Klenner)  ;  voice  is  damaged  and  sometimes 
entirely  lost  {Sebastiani) . 

Don't  forget  that  the  tonsil  is  a  natural  organ ; 
that  you  have  no  right  to  destroy  a  natural  organ ; 
that  the  physiologico-biological  values  of  the  ton- 
sil have  not  been  proved ;  that  by  enucleation  you 
destroy  values  of  which  you  have  no  knowledge; 


PRINCIPLES  OF  TREATMENT  37Q 

that  the  tonsil  has  important  mechanical  func- 
tions, a  buffer,  a  cushion,  a  fulcrum,  a  compen- 
sator; don't  forget  the  teaching  of  Frdnkel,  Von 
Levinstein,  Brieger,  Gorke,  Groher,  Escat  and 
Marage,  that  you  have  no  authority  to  destroy 
the  tonsil,  that  you  should  cure  it;  don't  forget 
the  assertion  of  MacBride  that  more  than  half 
the  people  who  do  not  complain  have  some  ab- 
normality which  should  not  be  operated  upon 
without  complaint;  dont  forget  that  Frederic 
Young  found  all  prima-donnas  with  extraordi- 
nary voices  had  big  tonsils;  dont  forget  that 
among  8,000  pupils  examined  by  Neustaedter, 
tonsils  are  largest  in  the  best  pupils,  and  that  the 
best  singers  have  fifty  per  cent  more  tonsils  than 
the  poorest ;  don't  forget  the  statement  of  Jacohi, 
that  so  many  operations  on  the  tonsils  would  not 
be  necessary  if  the  nose  were  kept  clean  ;^07i^f/or- 
get  that  Semon,  Mackenzie  and  all  other  conserva- 
tive authorities,  deplore  the  disastrous  eff'ects  of 
intemperate  surgery;  dont  forget  that  patients 
are  often  scared  into  operations ;  don't  forget  that 
many  patients,  who  could  just  as  well  be  operated 
on  in  the  physician's  office,  or  at  their  own  home, 
are  needlessly  sent  to  hospitals ;  don't  forget  that 
the  object  of  surgery  is  the  restoration  of  physio- 
logical function;  don't  forget  that  hunger  dulls 
the  school  child's  mind;  don't  forget  that  tonsil- 
lectomy is  an  American  operation;  don't  forget 
that  tonsillotomy  is  preferred  to  tonsillectomy,  by 
such  skilled  American  operators  as  Gleitsmann, 
Mackenzie,  Miller,  Gleason,  Grayson,  E.  L. 
Shurly,  Swain,  Ross  and  Farlow;  don't  forget 
that  tonsillectomy  is  never  performed  by  Price- 


380  THE    TONSILS    AND    THE    VOICE 

Brown,  Miller,  Gleitsmann,  Grayson  and  Jacohi; 
dont  forget  that  tonsillectomj^  is  never  done  by 
Von  Chiari,  Frdnhel,  Biieger,  Von  Levinstein, 
Escat,  Mar  age,  JLermoyez,  Moure,  Grober,  Se- 
mon;  dont  forget  that  enucleation  as  a  routine 
operation  is  opposed  by  Lack,  Synie,  Semon, 
Mackenzie,  Gleitsniann,  Gleason,  Grayson,  Sliiir- 
ly,  Swain,  Miller,  Ross,  Brown,  Farlow,  Jacohi, 
Von  Schrotter,  Loewenherg,  Von  Chiari,  Frdnkel, 
Brieger,  Goerke,  Von  Levinstein,  Escat,  Castex, 
Mar  age,  Lermoyez,  Moure,  Barth,  Gerher,  Gro- 
ber, Haymann,  and  Schmiegelow.  Dont  forget 
that  the  lingual  tonsil  sometimes  overlaps  and 
blends  with  the  lower  part  of  the  faucial  tonsil, 
as  stated  by  Escat. 

Don't  forget  that:  ''Inferiorly  the  faucial  ton- 
sil becomes  merged  in  the  border  of  the  tongue, 
blending  with  those  closed  follicles  which  are  scat- 
tered about  at  this  level,  and  which  are  known  as 
the  lingual  tonsil."     (Moure.) 

Dont  forget  Von  Levinstein :  '^'Complete  enu- 
cleation of  the  fancied  tonsil  is  an  impossible 
operation." 

Dont  forget  Grober:  ''It  is  not  possible  to  re- 
move the  tonsil  entire." 

Dont  forget  Brieger:  ''The  total  removal  of 
the  tonsil  is  not  possible." 

Dont  forget  Escat:  "Even  in  the  most  radical 
ablation  of  the  tonsil,  there  is  always  left  a  little 
adenoid  tissue." 

Don't  forget  Marage,  who  states  that  "tonsil 
tissue  cannot  be  wholly  removed." 

Don't  forget  John  N.  Mackenzie:  "The  so- 


PRINCIPLES  OF  TREATMENT  381 

called  complete  enucleation — the  chief  objection 
to  which  is  that  it  can  never  he  made  complete." 

Don't  forget  Von  Levinstein:  ''Adenoid  tissue 
is  continually  regenerated/' 

Don't  forget  Brieger:  "When  cut  out  the  tis- 
sue grows  again." 

Don't  forget  Goerke:  ''After  operations  the 
tissue  regrows." 

"The  adenoid  tissue  regenerates  in  all  cases 
after  removal  of  the  tonsils.  Those  same  causes 
which  led  to  the  first  hyperplasia,  also  lead  to  the 
new.  These  recurrences  occur  inore  often  than 
we  think,  hut  we  do  not  know  ahout  them.  Pa- 
tients don't  speak  ahout  the  return,  hecause  they 
don't  want  to  he  operated  on  again.  The  re- 
growth  is  never  as  great  as  the  first  hyperplasia." 

Based  upon  the  observations  of  Von  Levinstein, 
Brieger,  Goerke,  Groher,  Escat,  Moure,  Marage, 
and  Mackenzie,  the  so-called  "complete  enuclea- 
tions" must  hereafter  he  viewed  as  mere  tonsil- 
lotomies. 

Freely  admitting  the  great  improvement  in  the 
general  health  that  occasionally  follows  the  so- 
called  "complete"  operation,  may  we  not  justly 
consider  that  in  all  such  cases,  enough  tissue  has 
remained  after  the  operation,  as  Escat  distinctly 
claims,  to  perform  the  function  of  the  tonsil? 

And  finally,  is  it  not  highly  prohable  that  the 
henefit  obtained  is  in  direct  proportion  to  the 
amount  of  tonsillar  tissue  which  remains  after 
the  operation? 


mm  PRopEETi 

Jim  8  mt 

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